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Issa M, Kalliri V, Euteneuer S, Krümpelmann A, Seitz A, Sommerburg O, Westhoff JH, Syrbe S, Lenga P, Grutza M, Scherer M, Neumann JO, Baumann I, Unterberg AW, El Damaty A. The association of COVID-19 pandemic with the increase of sinogenic and otogenic intracranial infections in children: a 10-year retrospective comparative single-center study. Neurosurg Rev 2024; 47:205. [PMID: 38713418 DOI: 10.1007/s10143-024-02442-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 03/26/2024] [Accepted: 04/27/2024] [Indexed: 05/08/2024]
Abstract
OBJECTIVE Otitis media and sinusitis are common childhood infections, typically mild with good outcomes. Recent studies show a rise in intracranial abscess cases in children, raising concerns about a link to COVID-19. This study compares a decade of data on these cases before and after the pandemic. METHODS This retrospective comparative analysis includes pediatric patients diagnosed with otitis media and sinusitis, who later developed intracranial abscesses over the past decade. We collected comprehensive data on the number of cases, patient demographics, symptoms, treatment, and outcomes. RESULTS Between January 2013 and July 2023, our center identified 10 pediatric patients (median age 11.1years, range 2.2-18.0 years, 60% male) with intracranial abscesses from otitis media and sinusitis. Of these, 7 cases (70%, median age 9.7 years, range 2.2-18.0 years) occurred since the onset of the COVID-19 pandemic, while the remaining 3 cases (30%, median age 13.3 years, range 9.9-16.7 years) were treated before the pandemic. No significant differences were found in otolaryngological associations, surgical interventions, preoperative symptoms, lab findings, or postoperative antibiotics between the two groups. All patients showed positive long-term recovery. CONCLUSION This study reveals 5-fold increase of pediatric otogenic and sinogenic intracranial abscess cases in the last three-years since the onset of the COVID-19 pandemic. While further investigation is needed, these findings raise important questions about potential connections between the pandemic and the severity of otitis media and sinusitis complications in children. Understanding these associations can improve pediatric healthcare management during infectious disease outbreaks.
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Affiliation(s)
- Mohammed Issa
- Faculty of Medicine, Heidelberg University, Heidelberg, Germany.
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, D-69120, Heidelberg, Germany.
| | - Vasiliki Kalliri
- Faculty of Medicine, Heidelberg University, Heidelberg, Germany
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, D-69120, Heidelberg, Germany
| | - Sara Euteneuer
- Faculty of Medicine, Heidelberg University, Heidelberg, Germany
- Department of Otorhinolaryngology, Heidelberg University Hospital, Heidelberg, Germany
| | - Arne Krümpelmann
- Faculty of Medicine, Heidelberg University, Heidelberg, Germany
- Center for Pediatric and Adolescent Medicine, Department I, University Hospital Heidelberg, Heidelberg, Germany
| | - Angelika Seitz
- Faculty of Medicine, Heidelberg University, Heidelberg, Germany
- Deptartment of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Olaf Sommerburg
- Faculty of Medicine, Heidelberg University, Heidelberg, Germany
- Center for Pediatric and Adolescent Medicine, Department I, University Hospital Heidelberg, Heidelberg, Germany
| | - Jens H Westhoff
- Faculty of Medicine, Heidelberg University, Heidelberg, Germany
- Center for Pediatric and Adolescent Medicine, Department I, University Hospital Heidelberg, Heidelberg, Germany
| | - Steffen Syrbe
- Faculty of Medicine, Heidelberg University, Heidelberg, Germany
- Center for Pediatric and Adolescent Medicine, Department I, University Hospital Heidelberg, Heidelberg, Germany
| | - Pavlina Lenga
- Faculty of Medicine, Heidelberg University, Heidelberg, Germany
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, D-69120, Heidelberg, Germany
| | - Martin Grutza
- Faculty of Medicine, Heidelberg University, Heidelberg, Germany
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, D-69120, Heidelberg, Germany
| | - Moritz Scherer
- Faculty of Medicine, Heidelberg University, Heidelberg, Germany
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, D-69120, Heidelberg, Germany
| | - Jan-Oliver Neumann
- Faculty of Medicine, Heidelberg University, Heidelberg, Germany
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, D-69120, Heidelberg, Germany
| | - Ingo Baumann
- Faculty of Medicine, Heidelberg University, Heidelberg, Germany
- Department of Otorhinolaryngology, Heidelberg University Hospital, Heidelberg, Germany
| | - Andreas W Unterberg
- Faculty of Medicine, Heidelberg University, Heidelberg, Germany
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, D-69120, Heidelberg, Germany
| | - Ahmed El Damaty
- Faculty of Medicine, Heidelberg University, Heidelberg, Germany
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, D-69120, Heidelberg, Germany
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Lenga P, Kühlwein D, Schönenberger S, Neumann JO, Unterberg AW, Beynon C. The use of quantitative pupillometry in brain death determination: preliminary findings. Neurol Sci 2024; 45:2165-2170. [PMID: 38082049 PMCID: PMC11021299 DOI: 10.1007/s10072-023-07251-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 12/06/2023] [Indexed: 04/17/2024]
Abstract
PURPOSE Quantitative pupillometry (QP) has been increasingly applied in neurocritical care as an easy-to-use and reliable technique for evaluating the pupillary light reflex (PLR). Here, we report our preliminary findings on using QP for clinical brain death (BD) determination. MATERIALS This retrospective study included 17 patients ≥ 18 years (mean age, 57.3 years; standard deviation, 15.8 years) with confirmed BD, as defined by German Guidelines for the determination of BD. The PLR was tested using the NPi®-200 Pupillometer (Neuroptics, Laguna Hill, USA), a handheld infrared device automatically tracking and analyzing pupil dynamics over 3 s. In addition, pupil diameter and neurological pupil index (NPi) were also evaluated. RESULTS Intracerebral bleeding, subarachnoid hemorrhage, and hypoxic encephalopathy were the most prevalent causes of BD. In all patients, the NPi was 0 for both eyes, indicating the cessation of mid-brain function. The mean diameter was 4.9 mm (± 1.3) for the right pupil and 5.2 mm (±1.2) for the left pupil. CONCLUSIONS QP is a valuable tool for the BD certification process to assess the loss of PLR due to the cessation of brain stem function. Furthermore, implementing QP before the withdrawal of life-sustaining therapy in brain-injured patients may reduce the rate of missed organ donation opportunities. Further studies are warranted to substantiate the feasibility and potential of this technique in treating patients and identify suitable candidates for this technique during the BD certification process.
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Affiliation(s)
- Pavlina Lenga
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
| | - Daniel Kühlwein
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | | | - Jan-Oliver Neumann
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Andreas W Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Christopher Beynon
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
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Kaes M, Beynon C, Kiening K, Neumann JO, Jakobs M. Stereotactic frame-based biopsy of infratentorial lesions via the suboccipital-transcerebellar approach with the Zamorano-Duchovny stereotactic system-a retrospective analysis of 79 consecutive cases. Acta Neurochir (Wien) 2024; 166:147. [PMID: 38520537 PMCID: PMC10960772 DOI: 10.1007/s00701-024-06036-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 03/07/2024] [Indexed: 03/25/2024]
Abstract
OBJECTIVE Lesions of the posterior fossa (brainstem and cerebellum) are challenging in diagnosis and treatment due to the fact that they are often located eloquently and total resection is rarely possible. Therefore, frame-based stereotactic biopsies are commonly used to asservate tissue for neuropathological diagnosis and further treatment determination. The aim of our study was to assess the safety and diagnostic success rate of frame-based stereotactic biopsies for lesions in the posterior fossa via the suboccipital-transcerebellar approach. METHODS We performed a retrospective database analysis of all frame-based stereotactic biopsy cases at our institution since 2007. The aim was to identify all surgical cases for infratentorial lesion biopsies via the suboccipital-transcerebellar approach. We collected clinical data regarding outcomes, complications, diagnostic success, radiological appearances, and stereotactic trajectories. RESULTS A total of n = 79 cases of stereotactic biopsies for posterior fossa lesions via the suboccipital-transcerebellar approach (41 female and 38 male) utilizing the Zamorano-Duchovny stereotactic system were identified. The mean age at the time of surgery was 42.5 years (± 23.3; range, 1-87 years). All patients were operated with intraoperative stereotactic imaging (n = 62 MRI, n = 17 CT). The absolute diagnostic success rate was 87.3%. The most common diagnoses were glioma, lymphoma, and inflammatory disease. The overall complication rate was 8.7% (seven cases). All patients with complications showed new neurological deficits; of those, three were permanent. Hemorrhage was detected in five of the cases having complications. The 30-day mortality rate was 7.6%, and 1-year survival rate was 70%. CONCLUSIONS Our data suggests that frame-based stereotactic biopsies with the Zamorano-Duchovny stereotactic system via the suboccipital-transcerebellar approach are safe and reliable for infratentorial lesions bearing a high diagnostic yield and an acceptable complication rate. Further research should focus on the planning of safe trajectories and a careful case selection with the goal of minimizing complications and maximizing diagnostic success.
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Affiliation(s)
- Manuel Kaes
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
- Department of Neurosurgery, Division for Stereotactic Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
- Medical Faculty, Heidelberg University, Grabengasse 1, 69117, Heidelberg, Germany.
| | - Christopher Beynon
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- Medical Faculty, Heidelberg University, Grabengasse 1, 69117, Heidelberg, Germany
| | - Karl Kiening
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- Department of Neurosurgery, Division for Stereotactic Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- Medical Faculty, Heidelberg University, Grabengasse 1, 69117, Heidelberg, Germany
| | - Jan-Oliver Neumann
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- Department of Neurosurgery, Division for Stereotactic Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- Medical Faculty, Heidelberg University, Grabengasse 1, 69117, Heidelberg, Germany
| | - Martin Jakobs
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- Department of Neurosurgery, Division for Stereotactic Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- Medical Faculty, Heidelberg University, Grabengasse 1, 69117, Heidelberg, Germany
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Naser PV, Maurer MC, Fischer M, Karimian-Jazi K, Ben-Salah C, Bajwa AA, Jakobs M, Jungk C, Jesser J, Bendszus M, Maier-Hein K, Krieg SM, Neher P, Neumann JO. Deep learning aided preoperative diagnosis of primary central nervous system lymphoma. iScience 2024; 27:109023. [PMID: 38352223 PMCID: PMC10863328 DOI: 10.1016/j.isci.2024.109023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 12/21/2023] [Accepted: 01/22/2024] [Indexed: 02/16/2024] Open
Abstract
The preoperative distinction between glioblastoma (GBM) and primary central nervous system lymphoma (PCNSL) can be difficult, even for experts, but is highly relevant. We aimed to develop an easy-to-use algorithm, based on a convolutional neural network (CNN) to preoperatively discern PCNSL from GBM and systematically compare its performance to experienced neurosurgeons and radiologists. To this end, a CNN-based on DenseNet169 was trained with the magnetic resonance (MR)-imaging data of 68 PCNSL and 69 GBM patients and its performance compared to six trained experts on an external test set of 10 PCNSL and 10 GBM. Our neural network predicted PCNSL with an accuracy of 80% and a negative predictive value (NPV) of 0.8, exceeding the accuracy achieved by clinicians (73%, NPV 0.77). Combining expert rating with automated diagnosis in those cases where experts dissented yielded an accuracy of 95%. Our approach has the potential to significantly augment the preoperative radiological diagnosis of PCNSL.
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Affiliation(s)
- Paul Vincent Naser
- Heidelberg University Hospital, Department of Neurosurgery, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- Heidelberg University, Medical Faculty, Grabengasse 1, 69117 Heidelberg, Germany
- Heidelberg University Hospital, Division of Stereotactic Neurosurgery, Department of Neurosurgery, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- AI Health Innovation Cluster, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Miriam Cindy Maurer
- German Cancer Research Center (DKFZ) Heidelberg, Division of Medical Image Computing, Germany, Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
- Department of Medical Informatics, University Medical Center Göttingen, Von-Siebold-Straße 3, 37075 Göttingen, Germany
| | - Maximilian Fischer
- Heidelberg University, Medical Faculty, Grabengasse 1, 69117 Heidelberg, Germany
- German Cancer Research Center (DKFZ) Heidelberg, Division of Medical Image Computing, Germany, Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
- German Cancer Consortium (DKTK), partner site Heidelberg, Heidelberg, Germany
| | - Kianush Karimian-Jazi
- Heidelberg University, Medical Faculty, Grabengasse 1, 69117 Heidelberg, Germany
- Heidelberg University Hospital, Department of Neuroradiology, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Chiraz Ben-Salah
- Heidelberg University, Medical Faculty, Grabengasse 1, 69117 Heidelberg, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - Awais Akbar Bajwa
- Heidelberg University Hospital, Department of Neurosurgery, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- Heidelberg University, Medical Faculty, Grabengasse 1, 69117 Heidelberg, Germany
| | - Martin Jakobs
- Heidelberg University Hospital, Department of Neurosurgery, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- Heidelberg University, Medical Faculty, Grabengasse 1, 69117 Heidelberg, Germany
- Heidelberg University Hospital, Division of Stereotactic Neurosurgery, Department of Neurosurgery, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Christine Jungk
- Heidelberg University Hospital, Department of Neurosurgery, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- Heidelberg University, Medical Faculty, Grabengasse 1, 69117 Heidelberg, Germany
| | - Jessica Jesser
- Heidelberg University, Medical Faculty, Grabengasse 1, 69117 Heidelberg, Germany
- Heidelberg University Hospital, Department of Neuroradiology, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Martin Bendszus
- Heidelberg University, Medical Faculty, Grabengasse 1, 69117 Heidelberg, Germany
- Heidelberg University Hospital, Department of Neuroradiology, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Klaus Maier-Hein
- German Cancer Research Center (DKFZ) Heidelberg, Division of Medical Image Computing, Germany, Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
- German Cancer Consortium (DKTK), partner site Heidelberg, Heidelberg, Germany
- National Center for Tumor Diseases (NCT), NCT Heidelberg, a partnership between DKFZ and the University Medical Center Heidelberg, 69120 Heidelberg, Germany
- Pattern Analysis and Learning Group, Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- AI Health Innovation Cluster, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Sandro M. Krieg
- Heidelberg University Hospital, Department of Neurosurgery, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- Heidelberg University, Medical Faculty, Grabengasse 1, 69117 Heidelberg, Germany
| | - Peter Neher
- German Cancer Research Center (DKFZ) Heidelberg, Division of Medical Image Computing, Germany, Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
- German Cancer Consortium (DKTK), partner site Heidelberg, Heidelberg, Germany
- Pattern Analysis and Learning Group, Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Jan-Oliver Neumann
- Heidelberg University Hospital, Department of Neurosurgery, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- Heidelberg University, Medical Faculty, Grabengasse 1, 69117 Heidelberg, Germany
- Heidelberg University Hospital, Division of Stereotactic Neurosurgery, Department of Neurosurgery, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
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Alhalabi OT, Heene S, Landré V, Neumann JO, Haux D, Zweckberger K, Unterberg AW, Younsi A. Association of early surgery and absence of ataxia with full recovery after spinal intramedullary ependymoma resection. J Neurosurg Spine 2024; 40:185-195. [PMID: 37922542 DOI: 10.3171/2023.8.spine23606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 08/22/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE Spinal intramedullary ependymomas (IEs) represent a well-defined tumor entity usually warranting resection. Factors that determine full long-term neurological recovery after resection are seldomly reported on in larger clinical series. In this study, the authors aimed to highlight the neurological outcome of patients with IEs after resection, with a focus on full neurological recovery, and to explore possible risk factors for the absence of neurological amelioration to an optimal function after surgical treatment. METHODS A single-center retrospective analysis of all patients undergoing surgery for IEs between 2007 and 2021 was performed. Data collection included patient demographics, symptoms, clinical findings, histopathological diagnosis, surgical procedures, complications, and neurological outcome. Patients harboring a favorable outcome (modified McCormick Scale [mMS] grade of I) were compared with patients with a less favorable outcome (mMS grade ≥ II) at the final follow-up. RESULTS In total, 72 patients with a histologically diagnosed IE were included. IEs in those patients (41 males, 31 females; median age 51 [IQR 40-59] years) mostly occurred in the cervical (n = 40, 56%) or thoracic (n = 23, 32%) spine. Upon admission, motor deficits or gait deficits (mMS grade ≥ II) were present in 29 patients (40%), with a median mMS grade of II (IQR I-II). Gross-total resection was achieved in 60 patients (90%), and the rate of surgical complications was 7%. Histopathologically, 67 tumors (93%) were classified as WHO grade 2 ependymomas, 3 (4%) as WHO grade 1 subependymomas, and 2 (3%) as WHO grade 3 anaplastic ependymomas. After a mean follow-up of 863 ± 479 days, 37 patients (51%) had a fully preserved neurological function and 62 patients (86%) demonstrated an mMS grade of I or II. Comparison of favorable with unfavorable outcomes revealed an association of early surgery (within a year after symptom onset), the absence of ataxia or gait disorders, and a low mMS grade with full neurological recovery at the final follow-up. A subgroup of patients (n = 15, 21%) had nonresolving deterioration at the final follow-up, with no significant differences in relevant variables compared with the rest of the cohort. CONCLUSIONS The data presented solidify the role of early surgery in the management of spinal IEs, especially in patients with mild neurological deficits. Furthermore, the presence of gait disturbance or ataxia confers a higher risk of incomplete long-term recovery after spinal ependymoma resection. Because a distinct subgroup of patients had nonresolving deterioration, even when presenting with an uneventful history, further analyses into this subgroup of patients are required.
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Decraene B, Klein SP, Piper I, Gregson B, Enblad P, Ragauskas A, Citerio G, Chambers I, Neumann JO, Sahuquillo J, Kiening K, Moss L, Nilsson P, Donald R, Howells T, Lo M, Depreitere B. Decompressive craniectomy as a second/third-tier intervention in traumatic brain injury: A multicenter observational study. Injury 2023; 54:110911. [PMID: 37365094 DOI: 10.1016/j.injury.2023.110911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 06/08/2023] [Accepted: 06/19/2023] [Indexed: 06/28/2023]
Abstract
OBJECTIVES RESCUEicp studied decompressive craniectomy (DC) applied as third-tier option in severe traumatic brain injury (TBI) patients in a randomized controlled setting and demonstrated a decrease in mortality with similar rates of favorable outcome in the DC group compared to the medical management group. In many centers, DC is being used in combination with other second/third-tier therapies. The aim of the present study is to investigate outcomes from DC in a prospective non-RCT context. METHODS This is a prospective observational study of 2 patient cohorts: one from the University Hospitals Leuven (2008-2016) and one from the Brain-IT study, a European multicenter database (2003-2005). In thirty-seven patients with refractory elevated intracranial pressure who underwent DC as a second/third-tier intervention, patient, injury and management variables including physiological monitoring data and administration of thiopental were analysed, as well as Extended Glasgow Outcome score (GOSE) at 6 months. RESULTS In the current cohorts, patients were older than in the surgical RESCUEicp cohort (mean 39.6 vs. 32.3; p < 0.001), had higher Glasgow Motor Score on admission (GMS < 3 in 24.3% vs. 53.0%; p = 0.003) and 37.8% received thiopental (vs. 9.4%; p < 0.001). Other variables were not significantly different. GOSE distribution was: death 24.3%; vegetative 2.7%; lower severe disability 10.8%; upper severe disability 13.5%; lower moderate disability 5.4%; upper moderate disability 2.7%, lower good recovery 35.1%; and upper good recovery 5.4%. The outcome was unfavorable in 51.4% and favorable in 48.6%, as opposed to 72.6% and 27.4% respectively in RESCUEicp (p = 0.02). CONCLUSION Outcomes in DC patients from two prospective cohorts reflecting everyday practice were better than in RESCUEicp surgical patients. Mortality was similar, but fewer patients remained vegetative or severely disabled and more patients had a good recovery. Although patients were older and injury severity was lower, a potential partial explanation may be in the pragmatic use of DC in combination with other second/third-tier therapies in real-life cohorts. The findings underscore that DC maintains an important role in managing severe TBI.
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Affiliation(s)
| | | | - Ian Piper
- Southern General Hospital, Glasgow, United Kingdom
| | | | | | | | | | - Iain Chambers
- James Cook University Hospital, Middlesbrough, United Kingdom
| | | | | | - Karl Kiening
- Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Laura Moss
- Southern General Hospital, Glasgow, United Kingdom
| | | | - Rob Donald
- Stats Research, Scotland, United Kingdom
| | | | - Milly Lo
- University of Edinburgh, Edinburgh, United Kingdom
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Issa M, Neumann JO, Al-Maisary S, Dyckhoff G, Kronlage M, Kiening KL, Ishak B, Unterberg AW, Scherer M. Anterior Access to the Cervicothoracic Junction via Partial Sternotomy: A Clinical Series Reporting on Technical Feasibility, Postoperative Morbidity, and Early Surgical Outcome. J Clin Med 2023; 12:4107. [PMID: 37373799 DOI: 10.3390/jcm12124107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 06/06/2023] [Accepted: 06/15/2023] [Indexed: 06/29/2023] Open
Abstract
Surgical access to the cervicothoracic junction (CTJ) is challenging. The aim of this study was to assess technical feasibility, early morbidity, and outcome in patients undergoing anterior access to the CTJ via partial sternotomy. Consecutive cases with CTJ pathology treated via anterior access and partial sternotomy at a single academic center from 2017 to 2022 were retrospectively reviewed. Clinical data, perioperative imaging, and outcome were assessed with regards to the aims of the study. A total of eight cases were analyzed: four (50%) bone metastases, one (12.5%) traumatic instable fracture (B3-AO-Fracture), one (12.5%) thoracic disc herniation with spinal cord compression, and two (25%) infectious pathologic fractures from tuberculosis and spondylodiscitis. The median age was 49.9 years (range: 22-74 y), with a 75% male preponderance. The median Spinal Instability Neoplastic Score (SINS) was 14.5 (IQR: 5; range: 9-16), indicating a high degree of instability in treated cases. Four cases (50%) underwent additional posterior instrumentation. All surgical procedures were performed uneventfully, with no intraoperative complications. The median length of hospital stay was 11.5 days (IQR: 9; range: 6-20), including a median of 1 day in an intensive care unit (ICU). Two cases developed postoperative dysphagia related to stretching and temporary dysfunction of the recurrent laryngeal nerve. Both cases completely recovered at 3 months follow-up. No in-hospital mortality was observed. The radiological outcome was unremarkable in all cases, with no case of implant failure. One case died due to the underlying disease during follow-up. The median follow-up was 2.6 months (IQR: 23.8; range: 1-45.7 months). Our series indicates that the anterior approach to the cervicothoracic junction and upper thoracic spine via partial sternotomy can be considered an effective option for treatment of anterior spinal pathologies, exhibiting a reasonable safety profile. Careful case selection is essential to adequately balance clinical benefits and surgical invasiveness for these procedures.
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Affiliation(s)
- Mohammed Issa
- Department of Neurosurgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Jan-Oliver Neumann
- Department of Neurosurgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Sameer Al-Maisary
- Department of Cardiac Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Gerhard Dyckhoff
- Department of Otorhinolaryngology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Moritz Kronlage
- Department of Neuroradiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Karl L Kiening
- Department of Neurosurgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Basem Ishak
- Department of Neurosurgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Andreas W Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Moritz Scherer
- Department of Neurosurgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
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Neumann JO, Schmidt S, Nohman A, Jakobs M, Unterberg A. Routine ICU admission after brain tumor surgery: retrospective validation and critical appraisal of two prediction scores. Acta Neurochir (Wien) 2023; 165:1655-1664. [PMID: 37119320 PMCID: PMC10147995 DOI: 10.1007/s00701-023-05592-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 03/18/2023] [Indexed: 05/01/2023]
Abstract
BACKGROUND Routine admission to an intensive care unit (ICU) following brain tumor surgery has been a common practice for many years. Although this practice has been challenged by many authors, it has still not changed widely, mainly due to the lack of reliable data for preoperative risk assessment. Motivated by this dilemma, risk prediction scores for postoperative complications following brain tumor surgery have been developed recently. In order to improve the ICU admission policy at our institution, we assessed the applicability, performance, and safety of the two most appropriate risk prediction scores. METHODS One thousand consecutive adult patients undergoing elective brain tumor resection within 19 months were included. Patients with craniotomy for other causes, i.e., cerebral aneurysms and microvascular decompression, were excluded. The decision for postoperative ICU-surveillance was made by joint judgment of the operating surgeon and the anesthesiologist. All data and features relevant to the scores were extracted from clinical records and subsequent ICU or neurosurgical floor documentation was inspected for any postoperative adverse events requiring ICU admission. The CranioScore derived by Cinotti et al. (Anesthesiology 129(6):1111-20, 5) and the risk assessment score of Munari et al. (Acta Neurochir (Wien) 164(3):635-641, 15) were calculated and prognostic performance was evaluated by ROC analysis. RESULTS In our cohort, both scores showed only a weak prognostic performance: the CranioScore reached a ROC-AUC of 0.65, while Munari et al.'s score achieved a ROC-AUC of 0.67. When applying the recommended decision thresholds for ICU admission, 64% resp. 68% of patients would be classified as in need of ICU surveillance, and the negative predictive value (NPV) would be 91% for both scores. Lowering the thresholds in order to increase patient safety, i.e., 95% NPV, would lead to ICU admission rates of over 85%. CONCLUSION Performance of both scores was limited in our cohort. In practice, neither would achieve a significant reduction in ICU admission rates, whereas the number of patients suffering complications at the neurosurgical ward would increase. In future, better risk assessment measures are needed.
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Affiliation(s)
- Jan-Oliver Neumann
- Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany.
| | - Stephanie Schmidt
- Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Amin Nohman
- Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Martin Jakobs
- Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany
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Scherer M, Kausch L, Bajwa A, Neumann JO, Ishak B, Naser P, Vollmuth P, Kiening K, Maier-Hein K, Unterberg A. Automatic Planning Tools for Lumbar Pedicle Screws: Comparison and Validation of Planning Accuracy for Self-Derived Deep-Learning-Based and Commercial Atlas-Based Approaches. J Clin Med 2023; 12:jcm12072646. [PMID: 37048730 PMCID: PMC10094754 DOI: 10.3390/jcm12072646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/28/2023] [Accepted: 03/29/2023] [Indexed: 04/05/2023] Open
Abstract
Background: This ex vivo experimental study sought to compare screw planning accuracy of a self-derived deep-learning-based (DL) and a commercial atlas-based (ATL) tool and to assess robustness towards pathologic spinal anatomy. Methods: From a consecutive registry, 50 cases (256 screws in L1-L5) were randomly selected for experimental planning. Reference screws were manually planned by two independent raters. Additional planning sets were created using the automatic DL and ATL tools. Using Python, automatic planning was compared to the reference in 3D space by calculating minimal absolute distances (MAD) for screw head and tip points (mm) and angular deviation (degree). Results were evaluated for interrater variability of reference screws. Robustness was evaluated in subgroups stratified for alteration of spinal anatomy. Results: Planning was successful in all 256 screws using DL and in 208/256 (81%) using ATL. MAD to the reference for head and tip points and angular deviation was 3.93 ± 2.08 mm, 3.49 ± 1.80 mm and 4.46 ± 2.86° for DL and 7.77 ± 3.65 mm, 7.81 ± 4.75 mm and 6.70 ± 3.53° for ATL, respectively. Corresponding interrater variance for reference screws was 4.89 ± 2.04 mm, 4.36 ± 2.25 mm and 5.27 ± 3.20°, respectively. Planning accuracy was comparable to the manual reference for DL, while ATL produced significantly inferior results (p < 0.0001). DL was robust to altered spinal anatomy while planning failure was pronounced for ATL in 28/82 screws (34%) in the subgroup with severely altered spinal anatomy and alignment (p < 0.0001). Conclusions: Deep learning appears to be a promising approach to reliable automated screw planning, coping well with anatomic variations of the spine that severely limit the accuracy of ATL systems.
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Affiliation(s)
- Moritz Scherer
- Department of Neurosurgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Lisa Kausch
- Division of Medical Image Computing, German Cancer Research Center (DKFZ) Heidelberg, 69120 Heidelberg, Germany
| | - Akbar Bajwa
- Department of Neurosurgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Jan-Oliver Neumann
- Department of Neurosurgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Basem Ishak
- Department of Neurosurgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Paul Naser
- Department of Neurosurgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Philipp Vollmuth
- Department of Neuroradiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Karl Kiening
- Department of Neurosurgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Klaus Maier-Hein
- Division of Medical Image Computing, German Cancer Research Center (DKFZ) Heidelberg, 69120 Heidelberg, Germany
- Pattern Analysis and Learning Group, Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
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Alhalabi OT, Heene S, Landré V, Neumann JO, Scherer M, Ishak B, Kiening K, Zweckberger K, Unterberg AW, Younsi A. Spinal oncologic paraparesis: Analysis of neurological and surgical outcomes in patients with intramedullary, extramedullary, and extradural tumors. Front Oncol 2023; 12:1003084. [PMID: 36686806 PMCID: PMC9846080 DOI: 10.3389/fonc.2022.1003084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 12/12/2022] [Indexed: 01/05/2023] Open
Abstract
Objectives Paraparesis due to oncologic lesions of the spine warrants swift neurosurgical intervention to prevent permanent disability and hence maintain independence of affected patients. Clinical parameters that predict a favorable outcome after surgical intervention could aid decision-making in emergency situations. Methods Patients who underwent surgical intervention for paraparesis (grade of muscle strength <5 according to the British Medical Research Council grading system) secondary to spinal neoplasms between 2006 and 2020 were included in a single-center retrospective analysis. Pre- and postoperative clinical data were collected. The neurological status was assessed using the modified McCormick Disability Scale (mMcC) Score. In a univariate analysis, patients with favorable (discharge mMcC improved or stable at <3) and non-favorable outcome (discharge mMcC deteriorated or stable at >2) and different tumor anatomical compartments were statistically compared. Results 117 patients with oncologic paraparesis pertaining to intramedullary lesions (n=17, 15%), intradural extramedullary (n=24, 21%) and extradural lesions (n=76, 65%) with a mean age of 65.3 ± 14.6 years were included in the analysis. Thoracic tumors were the most common (77%), followed by lumbar and cervical tumors (13% and 12%, respectively). Surgery was performed within a mean of 36±60 hours of admission across all tumors and included decompression over a median of 2 segments (IQR:1-3) and mostly subtotal tumor resection (n=83, 71%). Surgical and medical complications were documented in 9% (n=11) and 7% (n=8) of cases, respectively. The median hospital length-of-stay was 9 (7-13) days. Upon discharge, the median mMcC score had improved from 3 to 2 (p<0.0001). At last follow-up (median 180; IQR 51-1080 days), patients showed an improvement in their mean Karnofsky Performance Score (KPS) from 51.7±18.8% to 65.3±20.4% (p<0.001). Localization in the intramedullary compartment, a high preoperative mMcC score, in addition to bladder and bowel dysfunction were associated with a non-favorable outcome (p<0.001). Conclusion The data presented on patients with spinal oncologic paraparesis provide a risk-benefit narrative that favors surgical intervention across all etiologies. At the same time, they outline clinical factors that confer a less-favorable outcome like intramedullary tumor localization, a high McCormick score and/or bladder and bowel abnormalities at admission.
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Affiliation(s)
- Obada T. Alhalabi
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany,*Correspondence: Obada T. Alhalabi,
| | - Stefan Heene
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Vincent Landré
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Jan-Oliver Neumann
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Moritz Scherer
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Basem Ishak
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Karl Kiening
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Klaus Zweckberger
- Department of Neurosurgery, City Hospital of Brunswick, Brunswick, Germany
| | | | - Alexander Younsi
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
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Scherer M, Kausch L, Ishak B, Norajitra T, Vollmuth P, Kiening K, Unterberg A, Maier-Hein K, Neumann JO. Development and validation of an automated planning tool for navigated lumbosacral pedicle screws using a convolutional neural network. Spine J 2022; 22:1666-1676. [PMID: 35584757 DOI: 10.1016/j.spinee.2022.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 05/05/2022] [Accepted: 05/12/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Navigation and robotic systems have been increasingly applied to spinal instrumentation but dedicated screw planning is a time-consuming prerequisite to tap the full potential of these techniques. PURPOSE To develop and validate an automated planning tool for lumbosacral pedicle screw placement using a convolutional neural network (CNN) to facilitate the planning process. STUDY DESIGN/SETTING Retrospective analysis and processing of CT and screw planning data randomly selected from a consecutive registry of CT-navigated instrumentations from a single academic institution. PATIENT SAMPLE Data from 179 cases was processed for CNN training and validation (155 for training, 24 for validation) leveraging a total of 1182 screws (1052 for training, 130 for validation). OUTCOME MEASURES Quantitative and qualitative (Gertzbein-Robbins classification [GR]) validation via comparison of automatically and manually planned reference screws, inter-rater and intra-rater variability. METHODS Annotated data from CT-navigated instrumentation was used to train a CNN operating in a vertebra instance-based approach employing a state-of-the-art U-Net framework. Internal five-fold cross-validation and external validation on an independent cohort not previously involved in training was performed. Quantitative validation of automatically planned screws was performed in comparison to corresponding manually planned screws by calculating the minimal absolute difference (MAD) of screw head and tip points, length and diameter, screw direction and Dice coefficient. Results were evaluated in relation to inter-rater and intra-rater variability of manual screw planning. RESULTS Automated screw planning was successful in all targeted 130 screws. Compared with manually planned screws as a reference, mean MAD of automatically planned screws was 4.61±2.27 mm for screw head, 3.96±2.19 mm for tip points and 5.51±3.64° for screw direction. These differences were either statistically comparable or significantly smaller when compared with interrater variability of manual screw planning (p>.99 for head point and direction, p=.004 for tip point, respectively). Mean Dice coefficient of 0.61±0.16 indicated significantly greater agreement of automatic screws with the manual reference compared with interrater agreement (Dice 0.56±0.18, p<.001). Automatically planned screws were marginally shorter (MAD 3.4±3.2 mm) and thinner (MAD mean 0.3±0.6 mm) compared with the manual reference, but with statistical significance (p<.0001, respectively). Automatically planned screws were GR grade A in 96.2% in qualitative validation. Planning time was significantly shorter with the automatic approach (0:41 min vs. 6:41 min, p<.0001). CONCLUSIONS We derived and validated a fully automated planning tool for lumbosacral pedicle screws using a CNN. Our validation showed noninferiority to manual screw planning and provided sufficient accuracy to facilitate and expedite the screw planning process. These results offer a high potential to improve workflows in spine surgery when integrated into navigation or robotic assistance systems.
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Affiliation(s)
- Moritz Scherer
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, Heidelberg 69120, Germany.
| | - Lisa Kausch
- Division of Medical Image Computing, German Cancer Research Center (DKFZ) Heidelberg, Im Neuenheimer Feld 280, Heidelberg 69120, Germany
| | - Basem Ishak
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, Heidelberg 69120, Germany
| | - Tobias Norajitra
- Division of Medical Image Computing, German Cancer Research Center (DKFZ) Heidelberg, Im Neuenheimer Feld 280, Heidelberg 69120, Germany
| | - Philipp Vollmuth
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, Heidelberg 69120, Germany
| | - Karl Kiening
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, Heidelberg 69120, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, Heidelberg 69120, Germany
| | - Klaus Maier-Hein
- Division of Medical Image Computing, German Cancer Research Center (DKFZ) Heidelberg, Im Neuenheimer Feld 280, Heidelberg 69120, Germany; Pattern Analysis and Learning Group, Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, Heidelberg 69120, Germany
| | - Jan-Oliver Neumann
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, Heidelberg 69120, Germany
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12
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Bösel J, Niesen WD, Salih F, Morris NA, Ragland JT, Gough B, Schneider H, Neumann JO, Hwang DY, Kantamneni P, James ML, Freeman WD, Rajajee V, Rao CV, Nair D, Benner L, Meis J, Klose C, Kieser M, Suarez JI, Schönenberger S, Seder DB. Effect of Early vs Standard Approach to Tracheostomy on Functional Outcome at 6 Months Among Patients With Severe Stroke Receiving Mechanical Ventilation: The SETPOINT2 Randomized Clinical Trial. JAMA 2022; 327:1899-1909. [PMID: 35506515 PMCID: PMC9069344 DOI: 10.1001/jama.2022.4798] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE Many patients with severe stroke have impaired airway protective reflexes, resulting in prolonged invasive mechanical ventilation. OBJECTIVE To test whether early vs standard tracheostomy improved functional outcome among patients with stroke receiving mechanical ventilation. DESIGN, SETTING, AND PARTICIPANTS In this randomized clinical trial, 382 patients with severe acute ischemic or hemorrhagic stroke receiving invasive ventilation were randomly assigned (1:1) to early tracheostomy (≤5 days of intubation) or ongoing ventilator weaning with standard tracheostomy if needed from day 10. Patients were randomized between July 28, 2015, and January 24, 2020, at 26 US and German neurocritical care centers. The final date of follow-up was August 9, 2020. INTERVENTIONS Patients were assigned to an early tracheostomy strategy (n = 188) or to a standard tracheostomy (control group) strategy (n = 194). MAIN OUTCOMES AND MEASURES The primary outcome was functional outcome at 6 months, based on the modified Rankin Scale score (range, 0 [best] to 6 [worst]) dichotomized to a score of 0 (no disability) to 4 (moderately severe disability) vs 5 (severe disability) or 6 (death). RESULTS Among 382 patients randomized (median age, 59 years; 49.8% women), 366 (95.8%) completed the trial with available follow-up data on the primary outcome (177 patients [94.1%] in the early group; 189 patients [97.4%] in the standard group). A tracheostomy (predominantly percutaneously) was performed in 95.2% of the early tracheostomy group in a median of 4 days after intubation (IQR, 3-4 days) and in 67% of the control group in a median of 11 days after intubation (IQR, 10-12 days). The proportion without severe disability (modified Rankin Scale score, 0-4) at 6 months was not significantly different in the early tracheostomy vs the control group (43.5% vs 47.1%; difference, -3.6% [95% CI, -14.3% to 7.2%]; adjusted odds ratio, 0.93 [95% CI, 0.60-1.42]; P = .73). Of the serious adverse events, 5.0% (6 of 121 reported events) in the early tracheostomy group vs 3.4% (4 of 118 reported events) were related to tracheostomy. CONCLUSIONS AND RELEVANCE Among patients with severe stroke receiving mechanical ventilation, a strategy of early tracheostomy, compared with a standard approach to tracheostomy, did not significantly improve the rate of survival without severe disability at 6 months. However, the wide confidence intervals around the effect estimate may include a clinically important difference, so a clinically relevant benefit or harm from a strategy of early tracheostomy cannot be excluded. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02377167.
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Affiliation(s)
- Julian Bösel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Neurology, Kassel General Hospital, Kassel, Germany
| | - Wolf-Dirk Niesen
- Department of Neurology, Freiburg University Hospital, Freiburg im Breisgau, Germany
| | - Farid Salih
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Nicholas A. Morris
- Department of Neurology, University of Maryland School of Medicine, Baltimore
| | - Jeremy T. Ragland
- Department of Neurosurgery, University of Texas Health Science Center, Houston
| | - Bryan Gough
- Department of Neurology, Ohio State University, Wexner Medical Center, Columbus
| | - Hauke Schneider
- Department of Neurology, Dresden University Hospital, Dresden, Germany
- Now with the Department of Neurology, Augsburg University Hospital Augsburg, Germany
| | - Jan-Oliver Neumann
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - David Y. Hwang
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Phani Kantamneni
- Department of Medicine, Kadlec Regional Medical Center, Richland, Washington
| | - Michael L. James
- Departments of Anesthesiology and Neurology, Duke University Hospital, Durham, North Carolina
| | - William D. Freeman
- Departments of Neurology, Neurologic Surgery, and Critical Care, Mayo Clinic, Jacksonville, Florida
| | | | - Chethan Venkatasubba Rao
- Department of Neurology, Neurosurgery and Center for Space Medicine, Baylor College of Medicine, Houston, Texas
| | | | - Laura Benner
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Jan Meis
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Christina Klose
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Meinhard Kieser
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - José I. Suarez
- Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - David B. Seder
- Department of Critical Care Services, Maine Medical Center, Portland, Maine
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Depreitere B, Citerio G, Smith M, Adelson PD, Aries MJ, Bleck TP, Bouzat P, Chesnut R, De Sloovere V, Diringer M, Dureanteau J, Ercole A, Hawryluk G, Hawthorne C, Helbok R, Klein SP, Neumann JO, Robba C, Steiner L, Stocchetti N, Taccone FS, Valadka A, Wolf S, Zeiler FA, Meyfroidt G. Cerebrovascular Autoregulation Monitoring in the Management of Adult Severe Traumatic Brain Injury: A Delphi Consensus of Clinicians. Neurocrit Care 2021; 34:731-738. [PMID: 33495910 PMCID: PMC8179892 DOI: 10.1007/s12028-020-01185-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 12/31/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Several methods have been proposed to measure cerebrovascular autoregulation (CA) in traumatic brain injury (TBI), but the lack of a gold standard and the absence of prospective clinical data on risks, impact on care and outcomes of implementation of CA-guided management lead to uncertainty. AIM To formulate statements using a Delphi consensus approach employing a group of expert clinicians, that reflect current knowledge of CA, aspects that can be implemented in TBI management and CA research priorities. METHODS A group of 25 international academic experts with clinical expertise in the management of adult severe TBI patients participated in this consensus process. Seventy-seven statements and multiple-choice questions were submitted to the group in two online surveys, followed by a face-to-face meeting and a third online survey. Participants received feedback on average scores and the rationale for resubmission or rephrasing of statements. Consensus on a statement was defined as agreement of more than 75% of participants. RESULTS Consensus amongst participants was achieved on the importance of CA status in adult severe TBI pathophysiology, the dynamic non-binary nature of CA impairment, its association with outcome and the inadvisability of employing universal and absolute cerebral perfusion pressure targets. Consensus could not be reached on the accuracy, reliability and validation of any current CA assessment method. There was also no consensus on how to implement CA information in clinical management protocols, reflecting insufficient clinical evidence. CONCLUSION The Delphi process resulted in 25 consensus statements addressing the pathophysiology of impaired CA, and its impact on cerebral perfusion pressure targets and outcome. A research agenda was proposed emphasizing the need for better validated CA assessment methods as well as the focused investigation of the application of CA-guided management in clinical care using prospective safety, feasibility and efficacy studies.
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Affiliation(s)
- B Depreitere
- Neurosurgery, University Hospitals Leuven, Herestraat 49, B-3000, Leuven, Belgium.
| | - G Citerio
- Intensive Care Medicine, School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - M Smith
- Neurocritical Care Unit, National Hospital for Neurology and Neurosurgery, University College London, London, UK
| | - P David Adelson
- Barrow Neurological Institute At Phoenix Childrens Hospital, Department of Child Health/Neurosurgery, University of Arizona College of Medicine, Tucson, AZ, USA
- Department of Neurosurgery, Mayo Clinic School of Medicine, School of Biological and Health Systems Engineering, Arizona State University, Tempe, AZ, USA
| | - M J Aries
- Department of Intensive Care, Maastricht University Medical Center, University of Maastricht, Maastricht, The Netherlands
| | - T P Bleck
- Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - P Bouzat
- Grenoble Alps Trauma Center, Department of Anesthesiology and Intensive Care Medicine, Grenoble University Hospital, Grenoble, France
| | - R Chesnut
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - V De Sloovere
- Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - M Diringer
- Department of Neurology, Barnes-Jewish Hospital, Washington University School of Medicine, St. Louis, MO, USA
| | - J Dureanteau
- Université Paris Sud - Hôpitaux Universitaires Paris-Sud, Paris, France
| | - A Ercole
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - G Hawryluk
- Section of Neurosurgery, University of Manitoba, Winnipeg, MB, Canada
| | - C Hawthorne
- Head and Neck Anaesthesia and Neurocritical Care, Institute of Neurological Sciences, Glasgow, UK
| | - R Helbok
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - S P Klein
- Neurosurgery, University Hospital Brussels, Brussels, Belgium
| | - J O Neumann
- Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany
| | - C Robba
- Policlinico San Martino, IRCCS for Oncology and Neuroscience, Genova, Italy
| | - L Steiner
- Anesthesiology, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - N Stocchetti
- Department of Physiopathology and Transplant, Milan University and Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - F S Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - A Valadka
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, VA, USA
| | - S Wolf
- Department of Neurosurgery, University Hospital Berlin Charité, Berlin, Germany
| | - F A Zeiler
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Department of Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada
- Centre on Aging, University of Manitoba, Winnipeg, Canada
| | - G Meyfroidt
- Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
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Campos B, Neumann JO, Hubert A, Adeberg S, El Shafie R, von Deimling A, Bendszus M, Debus J, Bernhardt D, Unterberg A. Analysis of a Surgical Series of 21 Cerebral Radiation Necroses. World Neurosurg 2020; 137:e462-e469. [PMID: 32058117 DOI: 10.1016/j.wneu.2020.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 01/31/2020] [Accepted: 02/01/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND There is no standard approach to differentiate cerebral radiation necrosis from tumor recurrence and no standard treatment pathway for symptomatic lesions. In addition, reports on histology-proven radiation necrosis and the underlying pathophysiology are scarce and highly relevant. METHODS Our monocentric, retrospective analysis included 21 histology-proven cerebral radiation necroses. Our study focused on 1) potential risk factors for the development of radiation necrosis, 2) radiologic and histopathologic features of individual necroses, and 3) the suitability of previously reported magnetic resonance imaging (MRI)-based methods to identify radiation necroses based on specific structural image features. RESULTS Average time between radiation treatment and development of necrosis was 4.68 years (95% confidence interval, 0.19-9.55 years). Matching available MRI data sets with those of patients with tumor lesions, we compared specificity and sensitivity of 3 previously reported methods to identify radionecrosis based on imaging criteria. In our hands, none of these methods reached a sensitivity ≥70%. Radionecrosis presented with large edema and showed increased levels of cell proliferation, as inferred by Ki-67 staining. Surgical removal of radiation necrosis proved to be a safe approach with low permanent morbidity (<5%) and no mortality. CONCLUSIONS Although the overall incidence of cerebral radiation necrosis is low, our data suggest an increasing incidence over the last 2 decades, which is likely associated with the use of stereotactic radiotherapy. There are no imaging standards to identify radiation necrosis on standard MRI with structural sequences. Surgical removal of radiation necrosis is associated with low morbidity and mortality.
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Affiliation(s)
- Benito Campos
- Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany.
| | - Jan-Oliver Neumann
- Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Alexander Hubert
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Sebastian Adeberg
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany; National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Rami El Shafie
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany; National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Andreas von Deimling
- Department of Neuropathology, University of Heidelberg, Heidelberg, Germany; Clinical Cooperation Unit Neuropathology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany; National Center for Tumor Diseases (NCT), Heidelberg, Germany; Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany; Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany; German Cancer Consortium (DKTK), Partner site Heidelberg, Heidelberg, Germany
| | - Denise Bernhardt
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany; National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany
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15
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Neumann JO, Campos B, Younes B, Jakobs M, Unterberg A, Kiening K, Hubert A. Evaluation of three automatic brain vessel segmentation methods for stereotactical trajectory planning. Comput Methods Programs Biomed 2019; 182:105037. [PMID: 31445207 DOI: 10.1016/j.cmpb.2019.105037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 08/10/2019] [Accepted: 08/12/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND AND OBJECTIVE Stereotactical procedures require exact trajectory planning to avoid blood vessels in the trajectory path. Innovation in imaging and image recognition techniques have facilitated the automatic detection of blood vessels during the planning process and may improve patient safety in the future. To assess the feasibility of a vessel detection and warning system using currently available imaging and vessel segmentation techniques. METHODS Image data were acquired from post-contrast, isovolumetric T1-weighted sequences (T1CE) and time.-of-flight MR angiography at 3T or 7T from a total of nine subjects. Vessel segmentation by a combination of a vessel-enhancement filter with subsequent level-set segmentation was evaluated using three different methods (Vesselness, FastMarching and LevelSet) in 45 stereotactic trajectories. Segmentation results were compared to a gold-standard of manual segmentation performed jointly by two human experts. RESULTS The LevelSet method performed best with a mean interclass correlation coefficient (ICC) of 0.76 [0.73, 0.81] compared to the FastMarching method with ICC 0.70 [0.67, 0.73] respectively. The Vesselness algorithm achieved clearly inferior overall performance with a mean ICC of 0.56 [0.53, 0.59]. The differences in mean ICC between all segmentation methods were statistically significant (p < 0.001 with post-hoc p < 0.026). The LevelSet method performed likewise good in MPRAGE and 3T-TOF images and excellent in 7T-TOF image data. The negative predictive value (NPV) was very high (>97%) for all methods and modalities. Positive predictive values (PPV) were found in the overall range of 65-90% likewise depending on algorithm and modality. This pattern reflects the disposition of all segmentation methods - in case of misclassification - to produce preferentially false-positive than false-negative results. In a clinical setting, two to three potential collision warnings would be given per trajectory on average with a PPV of around 50%. CONCLUSIONS It is feasible to integrate a clinically meaningful vessel detection and collision warning system into stereotactical planning software. Both, T1CE and MRA sequences are suitable as image data for such an application.
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Affiliation(s)
- Jan-Oliver Neumann
- Division Stereotactical and Functional Neurosurgery, Department of Neurosurgery, University Hospital Heidelberg, Germany.
| | - Benito Campos
- Department of Neurosurgery, University Hospital Heidelberg, Germany
| | - Bilal Younes
- Department of Neurosurgery, University Hospital Heidelberg, Germany
| | - Martin Jakobs
- Division Stereotactical and Functional Neurosurgery, Department of Neurosurgery, University Hospital Heidelberg, Germany
| | | | - Karl Kiening
- Division Stereotactical and Functional Neurosurgery, Department of Neurosurgery, University Hospital Heidelberg, Germany
| | - Alexander Hubert
- Department of Neuroradiology, University Hospital Heidelberg, Germany
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Petkus V, Preiksaitis A, Chaleckas E, Chomskis R, Zubaviciute E, Vosylius S, Rocka S, Rastenyte D, Aries MJ, Ragauskas A, Neumann JO. Optimal Cerebral Perfusion Pressure: Targeted Treatment for Severe Traumatic Brain Injury. J Neurotrauma 2019; 37:389-396. [PMID: 31583962 DOI: 10.1089/neu.2019.6551] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Identification of individual therapy targets is critical for traumatic brain injury (TBI) patients. Clinical outcomes depend on cerebrovascular autoregulation (CA) impairment. Here, we compare the effectiveness of optimal cerebral perfusion pressure (CPPopt)-targeted therapy in younger (<45 years of age) and elderly (≥45 years of age) TBI patients. Single-center multi-modal invasive arterial blood pressure(t), intracranial pressure (ICP)(t), cerebral perfusion pressure CPP(t), and CPPopt(t) monitoring (n = 81) was performed. ICM+ software was used for continuous CPPopt(t) status assessment by identification of pressure reactivity index (PRx). The most significant prognostic factors were age, Glasgow Coma Scale, serum glucose, and duration of longest CA ompairment event (LCAI) when PRx(t) >0.5 within 24 h after admission. The modeled accuracies for favorable and unfavorable outcome prediction were 86.5% and 90.9%, respectively. Age above 45 years and averaged ICP during all monitoring time above 21.3 mm Hg was associated with unfavorable outcome of an individual patient. Averaged CPP values close to CPPopt were associated with a better outcome in younger patients. Averaged ΔCPPopt <-5.0 mm Hg, averaged PRx >0.36, and LCAI >100 min were significantly associated with mortality for the younger patients. The critical values of averaged PRx >0.26 and LCAI >61 min were significantly associated with mortality for the elderly group. Autoregulation-guided treatment was important for individual TBI management, especially in younger patients. Further randomized multi-center studies are needed to prove final benefit.
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Affiliation(s)
- Vytautas Petkus
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania
| | - Aidanas Preiksaitis
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania.,Department of Neurology, Academy of Medicine, Lithuanian University of Health Sciences, Kaunas, Lithuania.,Clinic of Neurology and Neurosurgery, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Department of Neurosurgery, Republic Vilnius University Hospital, Vilnius, Lithuania
| | - Edvinas Chaleckas
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania
| | - Romanas Chomskis
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania
| | - Erika Zubaviciute
- Clinic of Neurology and Neurosurgery, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Saulius Vosylius
- Clinic of Neurology and Neurosurgery, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Department of Neurosurgery, Republic Vilnius University Hospital, Vilnius, Lithuania
| | - Saulius Rocka
- Clinic of Neurology and Neurosurgery, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Department of Neurosurgery, Republic Vilnius University Hospital, Vilnius, Lithuania
| | - Daiva Rastenyte
- Department of Neurology, Academy of Medicine, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Marcel J Aries
- Department of Intensive Care, University of Maastricht Medical Center, Maastricht, The Netherlands
| | - Arminas Ragauskas
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania
| | - Jan-Oliver Neumann
- Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany
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17
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Geletneky K, Hajda J, Angelova AL, Leuchs B, Capper D, Bartsch AJ, Neumann JO, Schöning T, Hüsing J, Beelte B, Kiprianova I, Roscher M, Bhat R, von Deimling A, Brück W, Just A, Frehtman V, Löbhard S, Terletskaia-Ladwig E, Fry J, Jochims K, Daniel V, Krebs O, Dahm M, Huber B, Unterberg A, Rommelaere J. Oncolytic H-1 Parvovirus Shows Safety and Signs of Immunogenic Activity in a First Phase I/IIa Glioblastoma Trial. Mol Ther 2017; 25:2620-2634. [PMID: 28967558 PMCID: PMC5768665 DOI: 10.1016/j.ymthe.2017.08.016] [Citation(s) in RCA: 173] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 08/17/2017] [Accepted: 08/17/2017] [Indexed: 01/09/2023] Open
Abstract
Oncolytic virotherapy may be a means of improving the dismal prognosis of malignant brain tumors. The rat H-1 parvovirus (H-1PV) suppresses tumors in preclinical glioma models, through both direct oncolysis and stimulation of anticancer immune responses. This was the basis of ParvOryx01, the first phase I/IIa clinical trial of an oncolytic parvovirus in recurrent glioblastoma patients. H-1PV (escalating dose) was administered via intratumoral or intravenous injection. Tumors were resected 9 days after treatment, and virus was re-administered around the resection cavity. Primary endpoints were safety and tolerability, virus distribution, and maximum tolerated dose (MTD). Progression-free and overall survival and levels of viral and immunological markers in the tumor and peripheral blood were also investigated. H-1PV treatment was safe and well tolerated, and no MTD was reached. The virus could cross the blood-brain/tumor barrier and spread widely through the tumor. It showed favorable pharmacokinetics, induced antibody formation in a dose-dependent manner, and triggered specific T cell responses. Markers of virus replication, microglia/macrophage activation, and cytotoxic T cell infiltration were detected in infected tumors, suggesting that H-1PV may trigger an immunogenic stimulus. Median survival was extended in comparison with recent meta-analyses. Altogether, ParvOryx01 results provide an impetus for further H-1PV clinical development.
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Affiliation(s)
- Karsten Geletneky
- Department of Neurosurgery, University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Jacek Hajda
- Coordination Centre for Clinical Trials, University Hospital, Marsilius-Arkaden, Tower West, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Assia L Angelova
- Department of Tumor Virology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 242, 69120 Heidelberg, Germany
| | - Barbara Leuchs
- Department of Tumor Virology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 242, 69120 Heidelberg, Germany
| | - David Capper
- Department of Neuropathology, University Hospital, Im Neuenheimer Feld 220, 69120 Heidelberg, Germany; Clinical Cooperation Unit Neuropathology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Andreas J Bartsch
- Department of Neuroradiology, University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Jan-Oliver Neumann
- Department of Neurosurgery, University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Tilman Schöning
- University Hospital Pharmacy, Im Neuenheimer Feld 670, 69120 Heidelberg, Germany
| | - Johannes Hüsing
- Coordination Centre for Clinical Trials, University Hospital, Marsilius-Arkaden, Tower West, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Birgit Beelte
- Coordination Centre for Clinical Trials, University Hospital, Marsilius-Arkaden, Tower West, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Irina Kiprianova
- Department of Tumor Virology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 242, 69120 Heidelberg, Germany
| | - Mandy Roscher
- Department of Tumor Virology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 242, 69120 Heidelberg, Germany
| | - Rauf Bhat
- Department of Tumor Virology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 242, 69120 Heidelberg, Germany
| | - Andreas von Deimling
- Department of Neuropathology, University Hospital, Im Neuenheimer Feld 220, 69120 Heidelberg, Germany; Clinical Cooperation Unit Neuropathology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Wolfgang Brück
- Department of Neuropathology, University Medical Center, Georg August University, 37099 Göttingen, Germany
| | - Alexandra Just
- Department of Tumor Virology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 242, 69120 Heidelberg, Germany
| | - Veronika Frehtman
- Department of Tumor Virology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 242, 69120 Heidelberg, Germany
| | - Stephanie Löbhard
- Eurofins BioPharma Product Testing, Behringstraße 6/8, 82152 Planegg, Germany
| | - Elena Terletskaia-Ladwig
- Laboratory Prof. Dr. Gisela Enders & Colleagues, MVZ and Institute of Virology, Infectious Diseases and Epidemiology e.V., Stuttgart, Germany
| | - Jeremy Fry
- ProImmune, The Magdalen Centre, Oxford Science Park, Oxford OX4 4GA, UK
| | - Karin Jochims
- IASON Consulting, Mühlenstraße 26A, 52382 Niederzier, Germany
| | - Volker Daniel
- Department of Transplantation Immunology, Institute of Immunology, University Hospital, Im Neuenheimer Feld 305, 69120 Heidelberg, Germany
| | - Ottheinz Krebs
- Oryx GmbH & Co. KG, Marktplatz 1, 85598 Baldham, Germany
| | - Michael Dahm
- Oryx GmbH & Co. KG, Marktplatz 1, 85598 Baldham, Germany
| | - Bernard Huber
- Oryx GmbH & Co. KG, Marktplatz 1, 85598 Baldham, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Jean Rommelaere
- Department of Tumor Virology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 242, 69120 Heidelberg, Germany.
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18
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Eidel O, Burth S, Neumann JO, Kieslich PJ, Sahm F, Jungk C, Kickingereder P, Bickelhaupt S, Mundiyanapurath S, Bäumer P, Wick W, Schlemmer HP, Kiening K, Unterberg A, Bendszus M, Radbruch A. Tumor Infiltration in Enhancing and Non-Enhancing Parts of Glioblastoma: A Correlation with Histopathology. PLoS One 2017; 12:e0169292. [PMID: 28103256 PMCID: PMC5245878 DOI: 10.1371/journal.pone.0169292] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 12/14/2016] [Indexed: 11/18/2022] Open
Abstract
PURPOSE To correlate histopathologic findings from biopsy specimens with their corresponding location within enhancing areas, non-enhancing areas and necrotic areas on contrast enhanced T1-weighted MRI scans (cT1). MATERIALS AND METHODS In 37 patients with newly diagnosed glioblastoma who underwent stereotactic biopsy, we obtained a correlation of 561 1mm3 biopsy specimens with their corresponding position on the intraoperative cT1 image at 1.5 Tesla. Biopsy points were categorized as enhancing (CE), non-enhancing (NE) or necrotic (NEC) on cT1 and tissue samples were categorized as "viable tumor cells", "blood" or "necrotic tissue (with or without cellular component)". Cell counting was done semi-automatically. RESULTS NE had the highest content of tissue categorized as viable tumor cells (89% vs. 60% in CE and 30% NEC, respectively). Besides, the average cell density for NE (3764 ± 2893 cells/mm2) was comparable to CE (3506 ± 3116 cells/mm2), while NEC had a lower cell density with 2713 ± 3239 cells/mm2. If necrotic parts and bleeds were excluded, cell density in biopsies categorized as "viable tumor tissue" decreased from the center of the tumor (NEC, 5804 ± 3480 cells/mm2) to CE (4495 ± 3209 cells/mm2) and NE (4130 ± 2817 cells/mm2). DISCUSSION The appearance of a glioblastoma on a cT1 image (circular enhancement, central necrosis, peritumoral edema) does not correspond to its diffuse histopathological composition. Cell density is elevated in both CE and NE parts. Hence, our study suggests that NE contains considerable amounts of infiltrative tumor with a high cellularity which might be considered in resection planning.
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Affiliation(s)
- Oliver Eidel
- Department of Neuroradiology, University of Heidelberg Medical Center, Heidelberg, Germany
- Department of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
- German Cancer Consortium (DKTK), Radiology, Heidelberg, Germany
| | - Sina Burth
- Department of Neuroradiology, University of Heidelberg Medical Center, Heidelberg, Germany
- Department of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
- German Cancer Consortium (DKTK), Radiology, Heidelberg, Germany
| | - Jan-Oliver Neumann
- Department of Neurosurgery, Division Stereotactic Neurosurgery, University of Heidelberg Medical Center, Heidelberg, Germany
| | - Pascal J. Kieslich
- Department of Psychology, School of Social Sciences, University of Mannheim, Mannheim, Germany
| | - Felix Sahm
- Department of Neuropathology, University of Heidelberg Medical Center, Heidelberg, Germany
| | - Christine Jungk
- Department of Neurosurgery, Division Stereotactic Neurosurgery, University of Heidelberg Medical Center, Heidelberg, Germany
| | - Philipp Kickingereder
- Department of Neuroradiology, University of Heidelberg Medical Center, Heidelberg, Germany
| | | | - Sibu Mundiyanapurath
- Department of Neurology, University of Heidelberg Medical Center, Heidelberg, Germany
| | - Philipp Bäumer
- Department of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Wolfgang Wick
- Department of Neurology, University of Heidelberg Medical Center, Heidelberg, Germany
| | | | - Karl Kiening
- Department of Neurosurgery, Division Stereotactic Neurosurgery, University of Heidelberg Medical Center, Heidelberg, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, Division Stereotactic Neurosurgery, University of Heidelberg Medical Center, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, University of Heidelberg Medical Center, Heidelberg, Germany
| | - Alexander Radbruch
- Department of Neuroradiology, University of Heidelberg Medical Center, Heidelberg, Germany
- Department of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
- German Cancer Consortium (DKTK), Radiology, Heidelberg, Germany
- * E-mail:
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19
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Eidel O, Neumann JO, Burth S, Kieslich PJ, Jungk C, Sahm F, Kickingereder P, Kiening K, Unterberg A, Wick W, Schlemmer HP, Bendszus M, Radbruch A. Automatic Analysis of Cellularity in Glioblastoma and Correlation with ADC Using Trajectory Analysis and Automatic Nuclei Counting. PLoS One 2016; 11:e0160250. [PMID: 27467557 PMCID: PMC4965093 DOI: 10.1371/journal.pone.0160250] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 07/15/2016] [Indexed: 11/18/2022] Open
Abstract
Objective Several studies have analyzed a correlation between the apparent diffusion coefficient (ADC) derived from diffusion-weighted MRI and the tumor cellularity of corresponding histopathological specimens in brain tumors with inconclusive findings. Here, we compared a large dataset of ADC and cellularity values of stereotactic biopsies of glioblastoma patients using a new postprocessing approach including trajectory analysis and automatic nuclei counting. Materials and Methods Thirty-seven patients with newly diagnosed glioblastomas were enrolled in this study. ADC maps were acquired preoperatively at 3T and coregistered to the intraoperative MRI that contained the coordinates of the biopsy trajectory. 561 biopsy specimens were obtained; corresponding cellularity was calculated by semi-automatic nuclei counting and correlated to the respective preoperative ADC values along the stereotactic biopsy trajectory which included areas of T1-contrast-enhancement and necrosis. Results There was a weak to moderate inverse correlation between ADC and cellularity in glioblastomas that varied depending on the approach towards statistical analysis: for mean values per patient, Spearman’s ρ = -0.48 (p = 0.002), for all trajectory values in one joint analysis Spearman’s ρ = -0.32 (p < 0.001). The inverse correlation was additionally verified by a linear mixed model. Conclusions Our data confirms a previously reported inverse correlation between ADC and tumor cellularity. However, the correlation in the current article is weaker than the pooled correlation of comparable previous studies. Hence, besides cell density, other factors, such as necrosis and edema might influence ADC values in glioblastomas.
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Affiliation(s)
- Oliver Eidel
- Department of Neuroradiology, University of Heidelberg Medical Center, Heidelberg, Germany
| | - Jan-Oliver Neumann
- Department of Neurosurgery, Division Stereotactic Neurosurgery, University of Heidelberg Medical Center, Heidelberg, Germany
| | - Sina Burth
- Department of Neuroradiology, University of Heidelberg Medical Center, Heidelberg, Germany
| | - Pascal J. Kieslich
- Department of Psychology, School of Social Sciences, University of Mannheim, Mannheim, Germany
| | - Christine Jungk
- Department of Neurosurgery, Division Stereotactic Neurosurgery, University of Heidelberg Medical Center, Heidelberg, Germany
| | - Felix Sahm
- Department of Neuropathology, University of Heidelberg Medical Center, Heidelberg, Germany
| | - Philipp Kickingereder
- Department of Neuroradiology, University of Heidelberg Medical Center, Heidelberg, Germany
| | - Karl Kiening
- Department of Neurosurgery, Division Stereotactic Neurosurgery, University of Heidelberg Medical Center, Heidelberg, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, Division Stereotactic Neurosurgery, University of Heidelberg Medical Center, Heidelberg, Germany
| | - Wolfgang Wick
- Neurology Clinic, University of Heidelberg Medical Center, Heidelberg, Germany
| | | | - Martin Bendszus
- Department of Neuroradiology, University of Heidelberg Medical Center, Heidelberg, Germany
| | - Alexander Radbruch
- Department of Neuroradiology, University of Heidelberg Medical Center, Heidelberg, Germany
- Department of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
- * E-mail:
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20
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Neumann JO, Giese H, Nagel AM, Biller A, Unterberg A, Meinzer HP. MR Angiography at 7T to Visualize Cerebrovascular Territories. J Neuroimaging 2016; 26:519-24. [PMID: 27074967 DOI: 10.1111/jon.12348] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 02/28/2016] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND There is considerable amount of interindividual variability in the size and location of the vascular territories of the major brain arteries. More data are needed to assess the amount of variability and the possible implications for further research and patient care. Arterial spin labeling (ASL) magnetic resonance imaging has been applied in various forms to facilitate noninvasive imaging of cerebrovascular flow territories, but it requires the definition of the flow territory of interest prior to image acquisition. OBJECTIVE Assessing the vascular territories of the major brain territories by using ultra-high-field time-of-flight (TOF) magnetic resonance angiography. METHODS We have developed an alternative method to ASL by simulating cerebrovascular dye injections. Following bias field normalization and segmentation of the vessels from 7 Tesla TOF imaging, a virtual model of the arterial vessel tree was generated and a simulation of dye dispersion into the brain tissue was performed. RESULTS The results provided by our method are consistent with the data obtained by autoptic dye injection studies in 23 human beings by van der Zwan in 1993. CONCLUSION Further technical improvements in imaging and segmentation techniques will improve the accuracy of the method and will facilitate the delineation of flow territories after image acquisition on even smaller subtrees of the cerebral vasculature.
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Affiliation(s)
- Jan-Oliver Neumann
- Department of Neurosurgery, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Henrik Giese
- Department of Neurosurgery, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Armin M Nagel
- Department of Medical Physics in Radiology, German Cancer Research Center, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Armin Biller
- Department of Neuroradiology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Hans-Peter Meinzer
- Division Medical and Biological Informatics, German Cancer Research Center, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
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21
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Enders F, Ruhparwar A, Unterberg A, Neumann JO. Distal catheter migration of a direct ventriculo-auricular shunt. Acta Neurochir (Wien) 2016; 158:615-6; discussion 616. [PMID: 26659256 DOI: 10.1007/s00701-015-2656-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 11/30/2015] [Indexed: 11/24/2022]
Affiliation(s)
- Frederik Enders
- Department of Neurosurgery, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
| | - Arjang Ruhparwar
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Jan-Oliver Neumann
- Department of Neurosurgery, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
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22
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Neumann JO, Giese H, Biller A, Nagel AM, Kiening K. Spatial Distortion in MRI-Guided Stereotactic Procedures: Evaluation in 1.5-, 3- and 7-Tesla MRI Scanners. Stereotact Funct Neurosurg 2015; 93:380-6. [PMID: 26671683 DOI: 10.1159/000441233] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 09/22/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) is replacing computed tomography (CT) as the main imaging modality for stereotactic transformations. MRI is prone to spatial distortion artifacts, which can lead to inaccuracy in stereotactic procedures. OBJECTIVE Modern MRI systems provide distortion correction algorithms that may ameliorate this problem. This study investigates the different options of distortion correction using standard 1.5-, 3- and 7-tesla MRI scanners. METHODS A phantom was mounted on a stereotactic frame. One CT scan and three MRI scans were performed. At all three field strengths, two 3-dimensional sequences, volumetric interpolated breath-hold examination (VIBE) and magnetization-prepared rapid acquisition with gradient echo, were acquired, and automatic distortion correction was performed. Global stereotactic transformation of all 13 datasets was performed and two stereotactic planning workflows (MRI only vs. CT/MR image fusion) were subsequently analysed. RESULTS Distortion correction on the 1.5- and 3-tesla scanners caused a considerable reduction in positional error. The effect was more pronounced when using the VIBE sequences. By using co-registration (CT/MR image fusion), even a lower positional error could be obtained. In ultra-high-field (7 T) MR imaging, distortion correction introduced even higher errors. However, the accuracy of non-corrected 7-tesla sequences was comparable to CT/MR image fusion 3-tesla imaging. CONCLUSION MRI distortion correction algorithms can reduce positional errors by up to 60%. For stereotactic applications of utmost precision, we recommend a co-registration to an additional CT dataset.
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Affiliation(s)
- Jan-Oliver Neumann
- Division of Stereotactic Neurosurgery, Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany
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23
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Paech D, Burth S, Windschuh J, Meissner JE, Zaiss M, Eidel O, Kickingereder P, Nowosielski M, Wiestler B, Sahm F, Floca RO, Neumann JO, Wick W, Heiland S, Bendszus M, Schlemmer HP, Ladd ME, Bachert P, Radbruch A. Nuclear Overhauser Enhancement imaging of glioblastoma at 7 Tesla: region specific correlation with apparent diffusion coefficient and histology. PLoS One 2015; 10:e0121220. [PMID: 25789657 PMCID: PMC4366097 DOI: 10.1371/journal.pone.0121220] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 01/30/2015] [Indexed: 01/24/2023] Open
Abstract
OBJECTIVE To explore the correlation between Nuclear Overhauser Enhancement (NOE)-mediated signals and tumor cellularity in glioblastoma utilizing the apparent diffusion coefficient (ADC) and cell density from histologic specimens. NOE is one type of chemical exchange saturation transfer (CEST) that originates from mobile macromolecules such as proteins and might be associated with tumor cellularity via altered protein synthesis in proliferating cells. PATIENTS AND METHODS For 15 patients with newly diagnosed glioblastoma, NOE-mediated CEST-contrast was acquired at 7 Tesla (asymmetric magnetization transfer ratio (MTRasym) at 3.3ppm, B1 = 0.7 μT). Contrast enhanced T1 (CE-T1), T2 and diffusion-weighted MRI (DWI) were acquired at 3 Tesla and coregistered. The T2 edema and the CE-T1 tumor were segmented. ADC and MTRasym values within both regions of interest were correlated voxelwise yielding the correlation coefficient rSpearman (rSp). In three patients who underwent stereotactic biopsy, cell density of 12 specimens per patient was correlated with corresponding MTRasym and ADC values of the biopsy site. RESULTS Eight of 15 patients showed a weak or moderate positive correlation of MTRasym and ADC within the T2 edema (0.16≤rSp≤0.53, p<0.05). Seven correlations were statistically insignificant (p>0.05, n = 4) or yielded rSp≈0 (p<0.05, n = 3). No trend towards a correlation between MTRasym and ADC was found in CE-T1 tumor (-0.31<rSp<0.28, p<0.05, n = 9; p>0.05, n = 6). The biopsy-analysis within CE-T1 tumor revealed a strong positive correlation between tumor cellularity and MTRasym values in two of the three patients (rSppatient3 = 0.69 and rSppatient15 = 0.87, p<0.05), while the correlation of ADC and cellularity was heterogeneous (rSppatient3 = 0.545 (p = 0.067), rSppatient4 = -0.021 (p = 0.948), rSppatient15 = -0.755 (p = 0.005)). DISCUSSION NOE-imaging is a new contrast promising insight into pathophysiologic processes in glioblastoma regarding cell density and protein content, setting itself apart from DWI. Future studies might be based on the assumption that NOE-mediated CEST visualizes cellularity more accurately than ADC, especially in the CE-T1 tumor region.
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Affiliation(s)
- Daniel Paech
- Department of Neuroradiology, University of Heidelberg Medical Center, Heidelberg, Germany
- Neurooncologic Imaging, Department of Radiology, Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Germany
| | - Sina Burth
- Department of Neuroradiology, University of Heidelberg Medical Center, Heidelberg, Germany
- Neurooncologic Imaging, Department of Radiology, Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Germany
| | - Johannes Windschuh
- Department of Medical Physics in Radiology, Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Germany
| | - Jan-Eric Meissner
- Neurooncologic Imaging, Department of Radiology, Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Germany
- Department of Medical Physics in Radiology, Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Germany
| | - Moritz Zaiss
- Department of Medical Physics in Radiology, Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Germany
| | - Oliver Eidel
- Department of Neuroradiology, University of Heidelberg Medical Center, Heidelberg, Germany
| | - Philipp Kickingereder
- Department of Neuroradiology, University of Heidelberg Medical Center, Heidelberg, Germany
| | - Martha Nowosielski
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
| | - Benedikt Wiestler
- Department of Neurology, University of Heidelberg Medical Center, Heidelberg, Germany
| | - Felix Sahm
- Department of Neuropathology, University of Heidelberg Medical Center, Heidelberg, Germany
| | - Ralf Omar Floca
- Department of Radiology, Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Germany
| | - Jan-Oliver Neumann
- Department of Neurosurgery, University of Heidelberg Medical Center, Heidelberg, Germany
| | - Wolfgang Wick
- Department of Neurology, University of Heidelberg Medical Center, Heidelberg, Germany
| | - Sabine Heiland
- Department of Neuroradiology, University of Heidelberg Medical Center, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, University of Heidelberg Medical Center, Heidelberg, Germany
| | - Heinz-Peter Schlemmer
- Department of Radiology, Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Germany
| | - Mark Edward Ladd
- Department of Medical Physics in Radiology, Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Germany
| | - Peter Bachert
- Department of Medical Physics in Radiology, Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Germany
| | - Alexander Radbruch
- Department of Neuroradiology, University of Heidelberg Medical Center, Heidelberg, Germany
- Neurooncologic Imaging, Department of Radiology, Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Germany
- * E-mail:
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Beynon C, Neumann JO, Bösel J, Unterberg AW, Kiening KL. Stereotactic biopsy and drainage of a brainstem abscess caused by Listeria monocytogenes. Neurol Med Chir (Tokyo) 2014; 53:263-5. [PMID: 23615421 DOI: 10.2176/nmc.53.263] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Listerial rhombencephalitis and brain abscesses are rare, but potentially life-threatening conditions. Early initiation of antibiotic therapy is crucial, but establishing the diagnosis of listerial brainstem abscess can be difficult. Stereotactic biopsy and drainage of space-occupying abscesses of the brainstem should be considered especially in cases of rapid clinical deterioration. We successfully performed stereotactic biopsy and drainage of a listerial brainstem abscess in a 42-year-old male patient who deteriorated despite antibiotic treatment, demonstrating that this approach is suitable in such patients.
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Affiliation(s)
- Christopher Beynon
- Department of Neurosurgery, Heidelberg University Hospital, 69120 Heidelberg, Germany.
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Bösel J, Schiller P, Hook Y, Andes M, Neumann JO, Poli S, Amiri H, Schönenberger S, Peng Z, Unterberg A, Hacke W, Steiner T. Stroke-related Early Tracheostomy versus Prolonged Orotracheal Intubation in Neurocritical Care Trial (SETPOINT): a randomized pilot trial. Stroke 2012. [PMID: 23204058 DOI: 10.1161/strokeaha.112.669895] [Citation(s) in RCA: 149] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND PURPOSE Optimal timing of tracheostomy in ventilated patients with severe stroke is unclear. We aimed to investigate feasibility, safety, and potential advantages of early tracheostomy in these intensive care unit (ICU) patients. METHODS This prospective, randomized, parallel-group, controlled, open, and outcome-masked pilot trial was conducted in neurological/neurosurgical ICUs of a university hospital. Patients with severe ischemic or hemorrhagic stroke and an estimated need for at least 2 weeks of ventilation were randomized to either early tracheostomy (within day 1-3 from intubation; early) or to standard tracheostomy (between day 7-14 from intubation if extubation could not be achieved or was not feasible; standard). The primary outcome was length of stay in the ICU; secondary outcomes were diverse aspects of the ICU course. RESULTS Sixty patients were randomized and analyzed. No differences were observed with regard to the primary outcome length of stay in the ICU (median 18 [interquartile range 16-28] versus 17 [interquartile range 13-22] days, median difference: 1 [-2 to 6]; P=0.38) or to most secondary outcomes, including adverse effects. Instead, use of sedatives (62% versus 42% of ICU stay, median difference 17.5 [3.3-29.2]; P=0.02), ICU mortality (ICU deaths 3 [10%] versus 14 [47%]; P<0.01) and 6-month mortality (deaths 8 [27%] versus 18 [60%]; P=0.02) were lower in the early group than in the standard group, respectively. CONCLUSIONS Early tracheostomy in ventilated intensive care stroke patients is feasible, and safe, and presumably reduces sedation need. Whether the suggested benefits in mortality and outcome truly exist has to be determined by a larger multicenter trial.
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Affiliation(s)
- Julian Bösel
- Department of Neurology, University of Heidelberg, Im Neuenheimer Feld 400, Heidelberg D-69121, Germany.
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Orakcioglu B, Sakowitz OW, Neumann JO, Kentar MM, Unterberg A, Kiening KL. Evaluation of a Novel Brain Tissue Oxygenation Probe in an Experimental Swine Model. Neurosurgery 2010; 67:1716-22; discussion 1722-3. [DOI: 10.1227/neu.0b013e3181f9bb5b] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Fischer L, Schoebinger M, Neumann JO, Müller S, Meinzer HP, Büchler MW, Schmied BM. Does preoperative analysis of intrahepatic venous anastomoses improve the surgeon's intraoperative decision making? Pilot data from a case report. Patient Saf Surg 2008; 2:19. [PMID: 18718022 PMCID: PMC2542344 DOI: 10.1186/1754-9493-2-19] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2008] [Accepted: 08/21/2008] [Indexed: 11/27/2022] Open
Abstract
Background Three-dimensional (3D) visualization is thought to improve the anatomical understanding of clinicians, thus improving patient safety. Case presentation A 58-year-old male was admitted to our hospital in April 2007 with a suspected metastasis of a sigmoid cancer in the Couinaud segment (CS) 7. The anatomical situation of this patient was analyzed using both a CT scan and 3D images. The initial CT scan revealed that the proximal part of the middle hepatic vein was completely missing and the metastasis in the CS 7 was closely attached to the right hepatic vein. After analyzing additional 3D images, it became clear that due to the close proximity of metastasis and right hepatic vein, the resection of the right hepatic vein was inevitable. Based on this 3D analysis, it was decided to perform a right-sided hemihepatectomy. In this case report, 3D visualization resulted in a faster and clearer understanding of the unique anatomical situation in a patient with complicated liver anatomy than transversal CT images. Conclusion The here presented data shows for the first time 3D visualization of intravenous anastomoses in the human liver. The information offered by 3D visualization is not redundant but rather serves as a true source of additional information, indicating the potential benefit of 3D visualization in surgical operation planning.
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Affiliation(s)
- Lars Fischer
- Department of Surgery, University of Heidelberg, INF 110, D-69120 Heidelberg, Germany.
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Neumann JO, Thorn M, Fischer L, Schöbinger M, Heimann T, Radeleff B, Schmidt J, Meinzer HP, Büchler MW, Schemmer P. Branching patterns and drainage territories of the middle hepatic vein in computer-simulated right living-donor hepatectomies. Am J Transplant 2006; 6:1407-15. [PMID: 16686764 DOI: 10.1111/j.1600-6143.2006.01315.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Full right hepatic grafts are most frequently used for adult-to-adult living donor liver transplantation (LDLT). One of the major problems is venous drainage of segments 5 and 8. Thus, this study was designed to provide information on venous drainage of right liver lobes for operation-planning. Fifty-six CT data sets from routine clinical imaging were evaluated retrospectively using a liver operation-planning system. We defined and analyzed venous drainage segments and the impact of anatomic variations of the middle hepatic vein (MHV) on venous outflow from segments 5 and 8. MHV variations led to significant shifts of segment 5 drainage between the middle and right hepatic vein. In cases with the most frequent MHV branching pattern (n = 33), a virtual hepatectomy closely right to the MHV intersected drainage vessels that provided drainage for 30% of the potential graft, not taking into account potential veno-venous shunts. In individuals with inferior MHV branches that extend far into segments 5 and 6 (n = 10), the overall graft volume at risk of impaired venous drainage increased by 5% (p < 0.001). If this is confirmed in clinical trials and correlated with intraoperative findings, the use of liver operation-planning systems would be beneficial to improve overall outcome after right lobe LDLT.
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Affiliation(s)
- J O Neumann
- Department of General Surgery, Ruprecht-Karls-University, Heidelberg, Germany
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