Clinical Outcomes and Cost Profiles for Cage and Allograft Anterior Cervical Discectomy and Fusion Procedures in the Adult Population: A Propensity Score-Matched Study

STUDY DESIGN

Retrospective cohort study.

PURPOSE

To characterize the postoperative outcomes and economic costs of anterior cervical discectomy and fusion (ACDF) procedures using synthetic biomechanical intervertebral cage (BC) and structural allograft (SA) implants.

OVERVIEW OF LITERATURE

ACDF is a common spine procedure that typically uses an SA or BC for the cervical fusion. Previous studies that compared the outcomes between the two implants were limited by small sample sizes, short-term postoperative outcomes, and procedures with single-level fusion.

METHODS

Adult patients who underwent an ACDF procedure in 2007-2016 were included. Patient records were extracted from MarketScan, a national registry that captures person-specific clinical utilization, expenditures, and enrollments across millions of inpatient, outpatient, and prescription drug services. Propensity-score matching (PSM) was employed to match the patient cohorts across demographic characteristics, comorbidities, and treatments.

RESULTS

Of 110,911 patients, 65,151 (58.7%) received BC implants while 45,760 (41.3%) received SA implants. Patients who underwent BC surgeries had slightly higher reoperation rates within 1 year after the index ACDF procedure (3.3% vs. 3.0%, p=0.004), higher postoperative complication rates (4.9% vs. 4.6%, p=0.022), and higher 90-day readmission rates (4.9% vs. 4.4%, p =0.001). After PSM, the postoperative complication rates did not vary between the two cohorts (4.8% vs. 4.6%, p=0.369), although dysphagia (2.2% vs. 1.8%, p<0.001) and infection (0.3% vs. 0.2%, p=0.007) rates remained higher for the BC group. Other outcome differences, including readmission and reoperation, decreased. Physician's fees remained high for BC implantation procedures.

CONCLUSIONS

We found marginal differences in clinical outcomes between BC and SA ACDF interventions in the largest published database cohort of adult ACDF surgeries. After adjusting for group-level differences in comorbidity burden and demographic characteristics, BC and SA ACDF surgeries showed similar clinical outcomes. Physician's fees, however, were higher for BC implantation procedures.

The Impact of Preoperative Myelopathy on Postoperative Outcomes among Anterior Cervical Discectomy and Fusion Procedures in the Nonelderly Adult Population: A Propensity-Score Matched Study

STUDY DESIGN

Retrospective cohort study.

PURPOSE

Anterior cervical discectomy and fusion (ACDF) is a common surgical intervention for patients diagnosed with cervical degenerative diseases with or without myelopathy. A thorough understanding of outcomes in patients with and without myelopathy undergoing ACDF is required because of the widespread utilization of ACDF for these indications.

OVERVIEW OF LITERATURE

Non-ACDF approaches achieved inferior outcomes in certain myelopathic cases. Studies have compared patient outcomes across procedures, but few have compared outcomes concerning myelopathic versus nonmyelopathic cohorts.

METHODS

The MarketScan database was queried from 2007 to 2016 to identify adult patients who were ≤65 years old, and underwent ACDF using the international classification of diseases 9th version and current procedural terminology codes. Nearest neighbor propensity-score matching was employed to balance patient demographics and operative characteristics between myelopathic and nonmyelopathic cohorts.

RESULTS

Of 107,480 patients who met the inclusion criteria, 29,152 (27.1%) were diagnosed with myelopathy. At baseline, the median age of patients with myelopathy was higher (52 years vs. 50 years, p <0.001), and they had a higher comorbidity burden (mean Charlson comorbidity index, 1.92 vs. 1.58; p <0.001) than patients without myelopathy. Patients with myelopathy were more likely to undergo surgical revision at 2 years (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.54-1.73) or are readmitted within 90 days (OR, 1.27; 95% CI, 1.20-1.34). After patient cohorts were matched, patients with myelopathy remained at elevated risk for reoperation at 2 years (OR, 1.55; 95% CI, 1.44-1.67) and postoperative dysphagia (2.78% vs. 1.68%, p <0.001) compared to patients without myelopathy.

CONCLUSIONS

We found inferior postoperative outcomes at baseline for patients with myelopathy undergoing ACDF compared to patients without myelopathy. Patients with myelopathy remained at significantly greater risk for reoperation and readmission after balancing potential confounding variables across cohorts, and these differences in outcomes were largely driven by patients with myelopathy undergoing 1-2 level fusions.

External Validation of the HATCH (Hemorrhage, Age, Treatment, Clinical State, Hydrocephalus) Score for Prediction of Functional Outcome After Subarachnoid Hemorrhage

BACKGROUND

The Hemorrhage, Age, Treatment, Clinical State, Hydrocephalus (HATCH) Score has previously shown to predict functional outcome in aneurysmal subarachnoid hemorrhage (aSAH).

OBJECTIVE

To validate the HATCH score.

METHODS

This is a pooled cohort study including prospective collected data on 761 patients with aSAH from 4 different hospitals. The HATCH score for prediction of functional outcome was validated using calibration and discrimination analysis (area under the curve). HATCH score model performance was compared with the World Federation of Neurosurgical Societies and Barrow Neurological Institute score.

RESULTS

At the follow-up of at least 6 months, favorable (Glasgow Outcome Score 4-5) and unfavorable functional outcomes (Glasgow Outcome Score 1-3) were observed in 512 (73%) and 189 (27%) patients, respectively. A higher HATCH score was associated with an increased risk of unfavorable outcome with a score of 1 showing a risk of 1.3% and a score of 12 yielding a risk of 67%. External validation showed a calibration intercept of -0.07 and slope of 0.60 with a Brier score of 0.157 indicating good model calibration and accuracy. With an area under the curve of 0.81 (95% CI 0.77-0.84), the HATCH score demonstrated superior discriminative ability to detect favorable outcome at follow-up compared with the World Federation of Neurosurgical Societies and Barrow Neurological Institute score with 0.72 (95% CI 0.67-0.75) and 0.63 (95% CI 0.59-0.68), respectively.

CONCLUSION

This multicenter external validation analysis confirms the HATCH score to be a strong independent predictor for functional outcome. Its incorporation into daily practice may be of benefit for goal-directed patient care in aSAH.

Casemix, management, and mortality of patients rreseceiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study

BACKGROUND

Traumatic brain injury (TBI) is increasingly recognised as being responsible for a substantial proportion of the global burden of disease. Neurosurgical interventions are an important aspect of care for patients with TBI, but there is little epidemiological data available on this patient population. We aimed to characterise differences in casemix, management, and mortality of patients receiving emergency neurosurgery for TBI across different levels of human development.

METHODS

We did a prospective observational cohort study of consecutive patients with TBI undergoing emergency neurosurgery, in a convenience sample of hospitals identified by open invitation, through international and regional scientific societies and meetings, individual contacts, and social media. Patients receiving emergency neurosurgery for TBI in each hospital's 30-day study period were all eligible for inclusion, with the exception of patients undergoing insertion of an intracranial pressure monitor only, ventriculostomy placement only, or a procedure for drainage of a chronic subdural haematoma. The primary outcome was mortality at 14 days postoperatively (or last point of observation if the patient was discharged before this time point). Countries were stratified according to their Human Development Index (HDI)-a composite of life expectancy, education, and income measures-into very high HDI, high HDI, medium HDI, and low HDI tiers. Mixed effects logistic regression was used to examine the effect of HDI on mortality while accounting for and quantifying between-hospital and between-country variation.

FINDINGS

Our study included 1635 records from 159 hospitals in 57 countries, collected between Nov 1, 2018, and Jan 31, 2020. 328 (20%) records were from countries in the very high HDI tier, 539 (33%) from countries in the high HDI tier, 614 (38%) from countries in the medium HDI tier, and 154 (9%) from countries in the low HDI tier. The median age was 35 years (IQR 24-51), with the oldest patients in the very high HDI tier (median 54 years, IQR 34-69) and the youngest in the low HDI tier (median 28 years, IQR 20-38). The most common procedures were elevation of a depressed skull fracture in the low HDI tier (69 [45%]), evacuation of a supratentorial extradural haematoma in the medium HDI tier (189 [31%]) and high HDI tier (173 [32%]), and evacuation of a supratentorial acute subdural haematoma in the very high HDI tier (155 [47%]). Median time from injury to surgery was 13 h (IQR 6-32). Overall mortality was 18% (299 of 1635). After adjustment for casemix, the odds of mortality were greater in the medium HDI tier (odds ratio [OR] 2·84, 95% CI 1·55-5·2) and high HDI tier (2·26, 1·23-4·15), but not the low HDI tier (1·66, 0·61-4·46), relative to the very high HDI tier. There was significant between-hospital variation in mortality (median OR 2·04, 95% CI 1·17-2·49).

INTERPRETATION

Patients receiving emergency neurosurgery for TBI differed considerably in their admission characteristics and management across human development settings. Level of human development was associated with mortality. Substantial opportunities to improve care globally were identified, including reducing delays to surgery. Between-hospital variation in mortality suggests changes at an institutional level could influence outcome and comparative effectiveness research could identify best practices.

FUNDING

National Institute for Health Research Global Health Research Group.

Pros and Cons of Early and Very Early Surgery for Traumatic Central Cord Syndrome with Spinal Stenosis: Literature Review and Case Report

BACKGROUND

 The case of a 69-year-old patient with an acute traumatic central cord syndrome (ATCCS) with preexisting spinal stenosis raised a discussion over the question of conservative versus surgical treatment in the acute setting. We provide a literature overview on the management (conservative vs. surgical treatment) of ATCCS with preexisting spinal stenosis.

METHODS

 We reviewed the literature concerning essential concepts for the management of ATCCS with spinal stenosis and cervical spinal cord injury. The data retrieved from these studies were applied to the potential management of an illustrative case report.

RESULTS

 Not rarely has ATCCS an unpredictable neurologic course because of its dynamic character with secondary injury mechanisms within the cervical spinal cord in the early phase, the possibility of functional deterioration, and the appearance of a neuropathic pain syndrome during late follow-up. The result of the literature review favors early surgical treatment in ATCCS patients with preexisting cervical stenosis.

CONCLUSION

 Reluctance toward aggressive and timely surgical treatment of ATCCS should at least be questioned in patients with preexisting spinal stenosis.

Development of a Complication- and Treatment-Aware Prediction Model for Favorable Functional Outcome in Aneurysmal Subarachnoid Hemorrhage Based on Machine Learning

BACKGROUND

Current prognostic tools in aneurysmal subarachnoid hemorrhage (aSAH) are constrained by being primarily based on patient and disease characteristics on admission.

OBJECTIVE

To develop and validate a complication- and treatment-aware outcome prediction tool in aSAH.

METHODS

This cohort study included data from an ongoing prospective nationwide multicenter registry on all aSAH patients in Switzerland (Swiss SOS [Swiss Study on aSAH]; 2009-2015). We trained supervised machine learning algorithms to predict a binary outcome at discharge (modified Rankin scale [mRS] ≤ 3: favorable; mRS 4-6: unfavorable). Clinical and radiological variables on admission ("Early" Model) as well as additional variables regarding secondary complications and disease management ("Late" Model) were used. Performance of both models was assessed by classification performance metrics on an out-of-sample test dataset.

RESULTS

Favorable functional outcome at discharge was observed in 1156 (62.0%) of 1866 patients. Both models scored a high accuracy of 75% to 76% on the test set. The "Late" outcome model outperformed the "Early" model with an area under the receiver operator characteristics curve (AUC) of 0.85 vs 0.79, corresponding to a specificity of 0.81 vs 0.70 and a sensitivity of 0.71 vs 0.79, respectively.

CONCLUSION

Both machine learning models show good discrimination and calibration confirmed on application to an internal test dataset of patients with a wide range of disease severity treated in different institutions within a nationwide registry. Our study indicates that the inclusion of variables reflecting the clinical course of the patient may lead to outcome predictions with superior predictive power compared to a model based on admission data only.

Factors which predict adverse events following surgery in adults with cervical spinal deformity

AIMS

The aim of this study was to identify the risk factors for adverse events following the surgical correction of cervical spinal deformities in adults.

METHODS

We identified adult patients who underwent corrective cervical spinal surgery between 1 January 2007 and 31 December 2015 from the MarketScan database. The baseline comorbidities and characteristics of the operation were recorded. Adverse events were defined as the development of a complication, an unanticipated deleterious postoperative event, or further surgery. Patients aged < 18 years and those with a previous history of tumour or trauma were excluded from the study.

RESULTS

A total of 13,549 adults in the database underwent primary corrective surgery for a cervical spinal deformity during the study period. A total of 3,785 (27.9%) had a complication within 90 days of the procedure, and 3,893 (28.7%) required further surgery within two years. In multivariate analysis, male sex (odds ratio (OR) 0.90 (95% confidence interval (CI) 0.8 to 0.9); p = 0.019) and a posterior approach (compared with a combined surgical approach, OR 0.66 (95% CI 0.5 to 0.8); p < 0.001) significantly decreased the risk of complications. Osteoporosis (OR 1.41 (95% CI 1.3 to 1.6); p < 0.001), dyspnoea (OR 1.48 (95% CI 1.3 to 1.6); p < 0.001), cerebrovascular accident (OR 1.81 (95% CI 1.6 to 2.0); p < 0.001), a posterior approach (compared with an anterior approach, OR 1.23 (95% CI 1.1 to 1.4); p < 0.001), and the use of bone morphogenic protein (BMP) (OR 1.22 (95% CI 1.1 to 1.4); p = 0.003) significantly increased the risks of 90-day complications. In multivariate regression analysis, preoperative dyspnoea (OR 1.50 (95% CI 1.3 to 1.7); p < 0.001), a posterior approach (compared with an anterior approach, OR 2.80 (95% CI 2.4 to 3.2; p < 0.001), and postoperative dysphagia (OR 2.50 (95% CI 1.8 to 3.4); p < 0.001) were associated with a significantly increased risk of further surgery two years postoperatively. A posterior approach (compared with a combined approach, OR 0.32 (95% CI 0.3 to 0.4); p < 0.001), the use of BMP (OR 0.48 (95% CI 0.4 to 0.5); p < 0.001) were associated with a significantly decreased risk of further surgery at this time.

CONCLUSION

The surgical approach and intraoperative use of BMP strongly influence the risk of further surgery, whereas the comorbidity burden and the characteristics of the operation influence the rates of early complications in adult patients undergoing corrective cervical spinal surgery. These data may aid surgeons in patient selection and surgical planning. Cite this article: Bone Joint J 2021;103-B(4):734-738.

Lower Extremity Motor Deficits Are Underappreciated in Patient-Reported Outcome Measures: Added Value of Objective Outcome Measures

Objective

The patient-reported outcome measure (PROM)-based evaluation in lumbar degenerative disc disease (DDD) is today’s gold standard but has limitations. We studied the impact of lower extremity motor deficits (LEMDs) on PROMs and a new objective outcome measure.

Methods

We evaluated patients with lumbar DDD from a prospective 2-center database. LEMDs were graded according to the British Medical Research Council (BMRC; 5 [normal] –0 [no movement]). The PROM-based evaluation included pain (visual analogue scale), disability (Oswestry Disability Index [ODI] & Roland-Morris Disability Index [RMDI]), and health-related quality of life (HRQoL; Short-Form 12 physical component summary/mental component summary & EuroQol-5D index). Objective functional impairment (OFI) was determined as age- and sex-adjusted Timed-Up and Go (TUG) test value.

Results

One hundred five of 375 patients (28.0%) had a LEMD. Patients with LEMD had slightly higher disability (ODI: 52.8 vs. 48.2, p = 0.025; RMDI: 12.6 vs. 11.3, p = 0.034) but similar pain and HRQoL scores. OFI T-scores were significantly higher in patients with LEMD (144.2 vs. 124.3, p = 0.006). When comparing patients with high- (BMRC 0–2) vs. low-grade LEMD (BMRC 3–4), no difference was evident for the PROM-based evaluation (all p > 0.05) but patients with high-grade LEMD had markedly higher OFI T-scores (280.9 vs. 136.0, p = 0.001). Patients with LEMD had longer TUG test times and OFI T-scores than matched controls without LEMDs.

Conclusion

Our data suggest that PROMs fail to sufficiently account for LEMD-associated disability, which is common and oftentimes bothersome to patients. The objective functional evaluation with the TUG test appears to be more sensitive to LEMD-associated disability. An objective functional evaluation of patients with LEMD appears reasonable.

Patterns of care for ruptured aneurysms of the middle cerebral artery: analysis of a Swiss national database (Swiss SOS)

OBJECTIVE

The objective of this study was to determine patterns of care and outcomes in ruptured intracranial aneurysms (IAs) of the middle cerebral artery (MCA) in a contemporary national cohort.

METHODS

The authors conducted a retrospective analysis of prospective data from a nationwide multicenter registry of all aneurysmal subarachnoid hemorrhage (aSAH) cases admitted to a tertiary care neurosurgical department in Switzerland in the years 2009-2015 (Swiss Study on Aneurysmal Subarachnoid Hemorrhage [Swiss SOS]). Patterns of care and outcomes at discharge and the 1-year follow-up in MCA aneurysm (MCAA) patients were analyzed and compared with those in a control group of patients with IAs in locations other than the MCA (non-MCAA patients). Independent predictors of a favorable outcome (modified Rankin Scale score ≤ 3) were identified, and their effect size was determined.

RESULTS

Among 1866 consecutive aSAH patients, 413 (22.1%) harbored an MCAA. These MCAA patients presented with higher World Federation of Neurosurgical Societies grades (p = 0.007), showed a higher rate of concomitant intracerebral hemorrhage (ICH; 41.9% vs 16.7%, p < 0.001), and experienced delayed cerebral ischemia (DCI) more frequently (38.9% vs 29.4%, p = 0.001) than non-MCAA patients. After adjustment for confounders, patients with MCAA were as likely as non-MCAA patients to experience DCI (aOR 1.04, 95% CI 0.74-1.45, p = 0.830). Surgical treatment was the dominant treatment modality in MCAA patients and at a significantly higher rate than in non-MCAA patients (81.7% vs 36.7%, p < 0.001). An MCAA location was a strong independent predictor of surgical treatment (aOR 8.49, 95% CI 5.89-12.25, p < 0.001), despite statistical adjustment for variables traditionally associated with surgical treatment, such as (space-occupying) ICH (aOR 1.73, 95% CI 1.23-2.45, p = 0.002). Even though MCAA patients were less likely to die during the acute hospitalization (aOR 0.52, 0.30-0.91, p = 0.022), their rate of a favorable outcome was lower at discharge than that in non-MCAA patients (55.7% vs 63.7%, p = 0.003). At the 1-year follow-up, 68.5% and 69.6% of MCAA and non-MCAA patients, respectively, had a favorable outcome (p = 0.676).

CONCLUSIONS

Microsurgical occlusion remains the predominant treatment choice for about 80% of ruptured MCAAs in a European industrialized country. Although patients with MCAAs presented with worse admission grades and greater rates of concomitant ICH, in-hospital mortality was lower and long-term disability was comparable to those in patients with non-MCAA.

Influence of the Intensive Care Unit Environment on the Reliability of the Montreal Cognitive Assessment

Background: Neuropsychological screening becomes increasingly important for the evaluation of subarachnoid hemorrhage (SAH) and stroke patients. It is often performed during the surveillance period on the intensive (ICU), while it remains unknown, whether the distraction in this environment influences the results. We aimed to study the reliability of the Montreal Cognitive Assessment (MoCA) in the ICU environment. Methods: Consecutive stable patients with recent brain injury (tumor, trauma, stroke, etc.) were evaluated twice within 36 h using official parallel versions of the MoCA (ΔMoCA). The sequence of assessment was randomized into (a) busy ICU first or (b) quiet office first with subsequent crossover. For repeated MoCA, we determined sequence, period, location effects, and the intraclass correlation coefficient (ICC). Results: N = 50 patients were studied [n = 30 (60%) male], with a mean age of 57 years. The assessment's sequence ["ICU first" mean ΔMoCA -1.14 (SD 2.34) vs. "Office first" -0.73 (SD 1.52)] did not influence the MoCA (p = 0.47). On the 2nd period, participants scored 0.96 points worse (SD 2.01; p = 0.001), indicating no MoCA learning effect but a possible difference in parallel versions. There was no location effect (p = 0.31) with ΔMoCA between locations (Office minus ICU) of -0.32 (SD 2.21). The ICC for repeated MoCA was 0.87 (95% CI 0.79-0.92). Conclusions: The reliability of the MoCA was excellent, independent from the testing environment being ICU or office. This finding is helpful for patient care and studies investigating the effect of a therapeutic intervention on the neuropsychological outcome after SAH, stroke or traumatic brain injury.

Correction to: Ruptured PICA aneurysms: presentation and treatment outcomes compared to other posterior circulation aneurysms. A Swiss SOS study

Incorrect authorgroup and authorname.

Ruptured PICA aneurysms: presentation and treatment outcomes compared to other posterior circulation aneurysms. A Swiss SOS study

BACKGROUND AND PURPOSE

Aneurysms of the posterior inferior cerebellar artery (PICA) are relatively uncommon and evidence is sparse about patients presenting with ruptured PICA aneurysms. We performed an analysis of the Swiss SOS national registry to describe clinical presentation, treatment pattern, and neurological outcome of patients with ruptured PICA aneurysms compared with other ruptured posterior circulation (PC) aneurysms.

METHODS

This was a retrospective analysis of anonymized data from the Swiss SOS registry (Swiss Study on Aneurysmal Subarachnoid Hemorrhage; 2009-2014). Patients with ruptured PC aneurysms were subdivided into a PICA and non-PICA group. Clinical, radiological, and treatment-related variables were identified, and their impact on the neurological outcome was determined in terms of modified Rankin score at discharge and at 1 year of follow-up for the two groups.

RESULTS

Data from 1864 aneurysmal subarachnoid hemorrhage patients were reviewed. There were 264 patients with a ruptured PC aneurysm. Seventy-four PICA aneurysms represented 28% of the series; clinical and radiological characteristics at admission were comparable between the PICA and non-PICA group. Surgical treatment was accomplished in 28% of patients in the PICA group and in the 4.8% of patients in the non-PICA group. No statistically significant difference was found between the two groups in terms of complications after treatment. Hydrocephalus requiring definitive shunt was needed in 21.6% of PICA patients (p = 0.6); cranial nerve deficit was present in average a quarter of the patients in both PICA and non-PICA group with no statistical difference (p = 0.3). A more favorable outcome (66.2%) was reported in the PICA group at discharge (p < 0.05) but this difference faded over time with a similar neurological outcome at 1-year follow-up (p = 0.09) between both PICA and non-PICA group. The Kaplan-Meyer estimation showed no significant difference in the mortality rate between both groups (p = 0.08).

CONCLUSIONS

In the present study, patients with ruptured PICA aneurysms had a favorable neurological outcome in more than two thirds of cases, similar to patients with other ruptured PC aneurysms. Surgical treatment remains a valid option in a third of cases with ruptured PICA aneurysms.

Correction to: Ruptured posterior circulation aneurysms: epidemiology, patterns of care, and outcomes from the Swiss SOS national registry

The name of Roy Thomas Daniel was incorrectly captured in the original manuscript.

Ruptured posterior circulation aneurysms: epidemiology, patterns of care, and outcomes from the Swiss SOS national registry

BACKGROUND

The treatment of ruptured posterior circulation aneurysms remains challenging despite progresses in the endovascular and neurosurgical techniques.

OBJECTIVE

To provide epidemiological characterization of subjects presenting with ruptured posterior circulation aneurysms in Switzerland and thereby assessing the treatment patterns and neurological outcomes.

METHODS

This is a retrospective analysis of the Swiss SOS registry for patients with aneurysmal subarachnoid hemorrhage. Patients were divided in 3 groups (upper, lower, and middle third) according to aneurysm location. Clinical, radiological, and treatment-related variables were identified and their impact on the neurological outcome was determined.

RESULTS

From 2009 to 2014, we included 264 patients with ruptured posterior circulation aneurysms. Endovascular occlusion was the most common treatment in all 3 groups (72% in the upper third, 68% in the middle third, and 58.8% in the lower third). Surgical treatment was performed in 11.3%. Favorable outcome (mRS ≤ 3) was found in 56% at discharge and 65.7% at 1 year. No significant difference in the neurological outcome were found among the three groups, in terms of mRS at discharge (p = 0.20) and at 1 year (p = 0.18). High WFNS grade, high Fisher grade at presentation, and rebleeding before aneurysm occlusion (p = 0.001) were all correlated with the risk of unfavorable neurological outcome (or death) at discharge and at 1 year.

CONCLUSIONS

In this study, endovascular occlusion was the principal treatment, with a favorable outcome for two-thirds of patients at discharge and at long term. These results are similar to high volume neurovascular centers worldwide, reflecting the importance of centralized care at specialized neurovascular centers.

Posterior open reduction and internal fixation of C1 fractures: the C-clamp technique

BACKGROUND

The treatment of isolated atlas (C1) fractures is still controversial. The surgical management usually involves an arthrodesis of the atlanto-axial (C1-C2) joint with or without occipital fixation. We reviewed the senior author's series of posterior only open reduction and internal fixation (ORIF) of isolated C1 fractures.

METHODS

Retrospective analysis of consecutive patients with isolated C1 fractures, treated in one institution by posterior only ORIF between 2005 and 2017. All fractures of C1 with concomitant C2 or occipital condyle fractures were excluded. The C1 arch was reduced with C1 lateral mass screws, connected with a transverse rod in a C-clamp fashion. We analyzed neck pain on the visual analog scale (VAS) and imaging signs of instability on follow-up.

RESULTS

We identified eight patients, six males, and two females with a mean age of 37.9 years (range 20-71 years). All were neurologically intact before surgery, none had a documented transverse ligament disruption, and the mean gap between the fractured pieces was 5.3 mm. Five patients were treated < 72 h of injury, two patients had failed halo vest for 8-10 weeks, and one patient was operated after 6 months because of painful pseudarthrosis despite wearing a hard collar. One patient developed a transient neurological deficit due to vertebral artery dissection that had resolved completely at time of follow-up. The mean follow-up after surgery was 12.6 months (range 1-49 months) and mean preoperative neck pain (VAS 5.1) was significantly decreased (VAS 0.8; p < 0.001). On follow-up radiological evaluation, no instability was noted in any patient.

CONCLUSIONS

Posterior ORIF of C1 fractures may be an option for patients who fail or do not wish to pursue conservative management. The particular advantage of this technique over C1-C2 arthrodesis is the preserved range of rotational motion. Mono-axial screws seem to provide better reduction capacity.

Routinely Performed Serial Follow-Up Imaging in Asymptomatic Patients With Multiple Cerebral Cavernous Malformations Has No Influence on Surgical Decision Making

Background: The best strategy to perform follow-up of patients with multiple cerebral cavernous malformations (mCCM) is unclear due to the unpredictable clinical course. Still, serial radiological follow-up is often performed. The objective of this work was to critically question whether active follow-up by serial imaging is justified and has an impact on clinical decision making.

Methods: We included all consecutive patients with mCCM treated and followed at our Department between 2006 and 2016. Patient data were collected and analyzed retrospectively.

Results: From a total number of 406 patients with CCM, n = 73 [18.0%; mean age at first diagnosis 45.2 years (±2.4 SE); n = 42 male (57.5 %)] were found to harbor multiple lesions (≤5 CCM in 58.9%; 6–25 in 21.9%; ≥ 25 in 19.2%). All of them were followed for a mean of 6.8 years (±0.85 SE). Conservative treatment was suggested in 43 patients over the complete follow-up period. Thirty patients underwent surgical extirpation of at least one CCM lesion. Forty-three surgical procedures were performed in total. During 500.5 follow-up years in total, routinely performed follow-up MRI in asymptomatic patients lead to an indication for surgery in only two occasions and even those two were questionable surgical indications.

Conclusion: Routinely performed follow-up MRI in asymptomatic patients with mCCM is highly questionable as there is no evidence for therapeutic relevance.

Decision-making and neurosurgeons' agreement in the management of aneurysmal subarachnoid haemorrhage based on computed tomography angiography

BACKGROUND

To determine the neurosurgeon's agreement in aneurysmal subarachnoid haemorrhage (aSAH) management with special emphasis on the rater's level of experience. A secondary aim was to analyse potential aneurysm variables associated with the therapeutic recommendation.

METHOD

Basic clinical information and admission computed tomography angiography (CTA) images of 30 consecutive aSAH patients were provided. Twelve neurosurgeons independently evaluated aneurysm characteristics and gave recommendations regarding the emergency management and aneurysm occlusion therapy. Inter-rater variability and predictors of treatment recommendation were evaluated.

RESULTS

There was an overall moderate agreement in treatment decision [κ = 0.43; 95% confidence interval ((CI), 0.387-0.474] with moderate agreement for surgical (κ = 0.43; 95% CI, 0.386-0.479) and endovascular treatment recommendation (κ = 0.45; 95% CI, 0.398-0.49). Agreement on detailed treatment recommendations including clip, coil, bypass, stent, flow diverter and ventriculostomy was low to moderate. Inter-rater agreement did not significantly differ between residents and consultants. Middle cerebral artery (MCA) aneurysm location was a positive predictor of surgical treatment [odds ratio (OR), 49.57; 95% CI, 10.416-235.865; p < 0.001], while patients aged >65 years (OR, 0.12; 95% CI, 0.03-0.0434; p = 0.001), fusiform aneurysm type (OR, 0.18; 95% CI, 0.044-0.747; p = 0.018) and intracerebral haematoma (ICA) aneurysm location (OR, 0.24; 95% CI, 0.088-0.643; p = 0.005) were associated with a recommendation for endovascular treatment.

CONCLUSIONS

Agreement on aSAH management varies considerably across neurosurgeons, while therapeutic decision-making is challenging on an individual patient level. However, patients aged >65 years, fusiform aneurysm shape and ICA location were associated with endovascular treatment recommendation, while MCA aneurysm location remains a surgical domain in the opinion of neurosurgeons without formal endovascular training.

Predictors of In-Hospital Death After Aneurysmal Subarachnoid Hemorrhage: Analysis of a Nationwide Database (Swiss SOS [Swiss Study on Aneurysmal Subarachnoid Hemorrhage])

BACKGROUND AND PURPOSE

To identify predictors of in-hospital mortality in patients with aneurysmal subarachnoid hemorrhage and to estimate their impact.

METHODS

Retrospective analysis of prospective data from a nationwide multicenter registry on all aneurysmal subarachnoid hemorrhage cases admitted to a tertiary neurosurgical department in Switzerland (Swiss SOS [Swiss Study on Aneurysmal Subarachnoid Hemorrhage]; 2009-2015). Both clinical and radiological independent predictors of in-hospital mortality were identified, and their effect size was determined by calculating adjusted odds ratios (aORs) using multivariate logistic regression. Survival was displayed using Kaplan-Meier curves.

RESULTS

Data of n=1866 aneurysmal subarachnoid hemorrhage patients in the Swiss SOS database were available. In-hospital mortality was 20% (n=373). In n=197 patients (10.6%), active treatment was discontinued after hospital admission (no aneurysm occlusion attempted), and this cohort was excluded from analysis of the main statistical model. In the remaining n=1669 patients, the rate of in-hospital mortality was 13.9% (n=232). Strong independent predictors of in-hospital mortality were rebleeding (aOR, 7.69; 95% confidence interval, 3.00-19.71; P<0.001), cerebral infarction attributable to delayed cerebral ischemia (aOR, 3.66; 95% confidence interval, 1.94-6.89; P<0.001), intraventricular hemorrhage (aOR, 2.65; 95% confidence interval, 1.38-5.09; P=0.003), and new infarction post-treatment (aOR, 2.57; 95% confidence interval, 1.43-4.62; P=0.002).

CONCLUSIONS

Several-and among them modifiable-factors seem to be associated with in-hospital mortality after aneurysmal subarachnoid hemorrhage. Our data suggest that strategies aiming to reduce the risk of rebleeding are most promising in patients where active treatment is initially pursued.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT03245866.

Neurodegenerative cerebrospinal fluid biomarkers tau and amyloid beta predict functional, quality of life, and neuropsychological outcomes after aneurysmal subarachnoid hemorrhage

Cerebrospinal fluid (CSF) biomarkers might be useful in predicting outcome after aneurysmal subarachnoid hemorrhage (aSAH). It was the aim to determine whether tau and amyloid beta CSF concentrations predict functional, health-related quality of life (hrQoL), and neuropsychological outcomes after aSAH. Ventricular CSF was obtained from n = 24 aSAH patients at admission (D0), day 2 (D2), and day 6 (D6). CSF total (t)Tau, phosphorylated (p)Tau_(181P), and amyloid beta_{(1-40 and 1-42)} (Aβ40/Aβ42) levels were compared between patients with favorable and unfavorable functional (modified Rankin Scale (mRS)), hrQoL (Euro-Qol (EQ-5D)), and neuropsychological outcomes at 3 (3 m) and 12 months (12 m). Patients with unfavorable functional (mRS 4-6) and hrQoL outcome (EQ-5D z-score ≤ - 1.0) at 3 and 12 m had higher CSF tTau/pTau and lower Aβ40/Aβ42 at D0, D2, and D6 with varying degrees of statistical significance. In terms of predicting neuropsychological outcome, CSF pTau showed a statistically significant correlation with the z-scores of executive function (r = - 0.7486, p = 0.008), verbal memory (r = - 0.8101, p = 0.002), attention (r = - 0.6498, p = 0.030), and visuospatial functioning (r = - 0.6944, p = 0.017) at 3 m. At 12 m, CSF pTau had statistically significant correlations with the z-scores of verbal memory (r = - 0.7473, p = 0.008) and visuospatial functioning (r = - 0.6678, p = 0.024). In conclusion, higher tTau/pTau and lower Aβ40/Aβ42 CSF levels predict unfavorable long-term functional and hrQoL outcomes. Neuropsychological deficits correlate with increased CSF tTau and pTau concentrations.

Computed tomography angiography spot sign predicts intraprocedural aneurysm rupture in subarachnoid hemorrhage

INTRODUCTION

To analyze whether the computed tomography angiography (CTA) spot sign predicts the intraprocedural rupture rate and outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

From a prospective nationwide multicenter registry database, 1023 patients with aneurysmal subarachnoid hemorrhage (aSAH) were analyzed retrospectively. Descriptive statistics and logistic regression analysis were used to compare spot sign-positive and -negative patients with aneurysmal intracerebral hemorrhage (aICH) for baseline characteristics, aneurysmal and ICH imaging characteristics, treatment and admission status as well as outcome at discharge and 1-year follow-up (1YFU) using the modified Rankin Scale (mRS).

RESULTS

A total of 218 out of 1023 aSAH patients (21%) presented with aICH including 23/218 (11%) patients with spot sign. Baseline characteristics were comparable between spot sign-positive and -negative patients. There was a higher clip-to-coil ratio in patients with than without aICH (both spot sign positive and negative). Median aICH volume was significantly higher in the spot sign-positive group (50 ml, 13-223 ml) than in the spot sign-negative group (18 ml, 1-416; p < 0.0001). Patients with a spot sign-positive aICH thus were three times as likely as those with spot sign-negative aICH to show an intraoperative aneurysm rupture [odds ratio (OR) 3.04, 95% confidence interval (CI) 1.04-8.92, p = 0.046]. Spot sign-positive aICH patients showed a significantly worse mRS at discharge (p = 0.039) than patients with spot sign-negative aICH (median mRS 5 vs. 4). Logistic regression analysis showed that the spot sign was an aICH volume-dependent predictor for outcome. Both spot sign-positive and -negative aICH patients showed comparable rates of hospital death, death at 1YFU and mRS at 1YFU.

CONCLUSION

In this multicenter data analysis, patients with spot sign-positive aICH showed higher aICH volumes and a higher rate of intraprocedural aneurysm rupture, but comparable long-term outcome to spot sign-negative aICH patients.

The value of short-term pain relief in predicting the 1-month outcome of 'indirect' cervical epidural steroid injections

BACKGROUND

Clinical management after epidural steroid injections (ESI) of patients with radiculopathy secondary to a cervical disc herniation (CDH) is uncertain. This study aims to determine whether short-term arm pain alleviation following computed tomography-guided 'indirect' cervical ESI can predict the 1-month outcome.

METHODS

We conducted a prospective observation of 45 consecutive patients at a tertiary radiological department. Study components were visual analog scale arm and neck pain at baseline, 15, 30, and 45 min, 1, 2, and 4 h, on days 1-14, 1 month, and at 1 year. Health-related quality of life and functional impairment were assessed using the short form-12 and Neck Pain and Disability Scale. Patients who reported ≥80 % persisting arm pain, as well as patients who underwent a second injection or an operation within 1 month were defined as 'non-responders'. Logistic regression was used to analyze the effect size of the relationship between >50 % pain relief at any given study visit and responder status.

RESULTS

Patients experiencing a >50 % pain reduction 4 h after the injection were four times as likely to be responders as those experiencing ≤50 % pain reduction (OR 4.04, 95 % CI 1.10-14.87). The effect was strongest on days 5-6 (OR 18.37, 95 % CI 3.39-99.64) and remained significant until day 14.

CONCLUSIONS

The results of this study can guide physicians in managing patients with CDH: a ≤50 % arm pain relief within 1 week after an 'indirect' cervical ESI predicts an unfavorable 1-month outcome and suggests that other treatment options may be considered at an earlier point in time.

Correlation of pain, functional impairment, and health-related quality of life with radiological grading scales of lumbar degenerative disc disease

BACKGROUND

It is generally believed that radiological signs of lumbar degenerative disc disease (DDD) are associated with increased pain and functional impairment as well as lower health-related quality of life (HRQoL). Our aim was to assess the association of the Modic and Pfirrmann grading scales with established outcome questionnaires and the timed-up-and-go (TUG) test.

METHODS

In a prospective two-center study with patients scheduled for lumbar spine surgery, visual analogue scale (VAS) for back and leg pain, Roland-Morris Disability Index, Oswestry Disability Index and HRQoL, as determined by the Short-Form (SF)-12 and the Euro-Qol, were recorded. Functional mobility was measured with the TUG test. Modic type (MOD) and Pfirrmann grade (PFI) of the affected lumbar segment were assessed with preoperative imaging. Uni- and multivariate logistic regression analysis was performed to estimate the effect size of the relationship between clinical and radiological findings.

RESULTS

Two hundred eighty-four patients (mean age 58.5, 119 (42 %) females) were enrolled. None of the radiological grading scales were significantly associated with any of the subjective or objective clinical tests. There was a tendency for higher VAS back pain (3.48 vs. 4.14, p = 0.096) and lower SF-12 physical component scale (31.2 vs. 29.4, p = 0.065) in patients with high PFI (4-5) as compared to patients with low PFI (0-3). In the multivariate analysis, patients with MOD changes of the vertebral endplates were 100 % as likely as patients without changes to show an impaired TUG test performance (odds ratio (OR) 1.00, 95 % confidence interval (CI) 0.56-1.80, p = 0.982). Patients with high PFI were 145 % as likely as those with low PFI to show an impaired TUG test performance (OR 1.45, 95 % CI 0.79-2.66, p = 0.230).

CONCLUSIONS

There was no association between established outcome questionnaires of symptom severity and two widely used radiological classifications in patients undergoing surgery for lumbar DDD.

[Minimally invasive spine surgery: past and present]

In the early twentieth century, the understanding of spine biomechanics and the advent of surgical techniques of the lumbar spine, led to the currently emerging concept of minimal invasive spine surgery, By reducing surgical access, blood loss, infection rate and general morbidity, functional prognosis of patients is improved. This is a real challenge for the spine surgeon, who has to maintain a good operative result by significantly reducing surgical collateral damages due to the relatively traumatic conventional access.

Little-known Swiss contributions to the description, diagnosis, and surgery of lumbar disc disease before the Mixter and Barr era

The understanding of lumbar spine pathologies made substantial progress at the turn of the twentieth century. The authors review the original publication of Otto Veraguth in 1929 reporting on the successful resection of a herniated lumbar disc, published exclusively in the German language. His early report is put into the historical context, and its impact on the understanding of pathologies of the intervertebral disc (IVD) is estimated. The Swiss surgeon and Nobel Prize laureate Emil Theodor Kocher was among the first physicians to describe the traumatic rupture of the IVD in 1896. As early as 1909 Oppenheim and Krause published 2 case reports on surgery for a herniated lumbar disc. Goldthwait was the first physician to delineate the etiopathogenes is between annulus rupture, symptoms of sciatica, and neurological signs in his publication of 1911. Further publications by Middleton and Teacher in 1911 and Schmorl in 1929 added to the understanding of lumbar spinal pathologies. In 1929, the Swiss neurologist Veraguth (surgery performed by Hans Brun) and the American neurosurgeon Walter Edward Dandy both published their early experiences with the surgical therapy of a herniated lumbar disc. Veraguth's contribution, however, has not been appreciated internationally to date. The causal relationship between lumbar disc pathology and sciatica remained uncertain for some years to come. The causal relationship was not confirmed until Mixter and Barr's landmark paper in 1934 describing the association of sciatica and lumbar disc herniation, after which the surgical treatment became increasingly popular. Veraguth was among the first physicians to report on the clinical course of a patient with successful resection of a herniated lumbar disc. His observations should be acknowledged in view of the limited experience and literature on this ailment at that time.

Resection of an intramedullary high cervical metastasis from a malignant mixed Muellerian tumour

We present a 66-year-old female patient with a high cervical intramedullary metastasis from a malignant mixed Muellerian tumour (MMMT; carcinosarcoma) with concomitant syringomyelia. She was admitted to our clinic with symptoms of cervical myelopathy. MRI revealed an intramedullary tumour of 2.6cm×1.2cm at the cervical vertebral body C2. We performed a laminectomy on C2 followed by a dorsal median myelotomy from C1 to C3 to resect the tumour. The surgical intervention removed the tumour completely and resolved the syringomyelia. During the 36months of follow-up, the patient presented in a stable condition with no evidence of tumour recurrence. To our knowledge, this is the first report of an intramedullary metastasis of a MMMT.

Calcifying pseudoneoplasms of the neuraxis (CAPNON): clinical features and therapeutic options

INTRODUCTION

Calcifying pseudoneoplasms of the neuraxis (CAPNON) are rare, slow-growing lesions occurring anywhere in the central nervous system (CNS). Since their first description in 1978, only 39 cases have been reported in the literature.

METHODS

The cases of two patients with histopathologically verified diagnoses of CAPNON are presented. Thereafter, we review all reports published so far with respect to study type, number of patients, anatomical area (intracranial, spinal, or both), clinical presentation, radiological presentation, therapy, duration of follow-up, incidence and type of complication, and outcome. Furthermore, current recommendations for the management of spinal and cerebral CAPNON are discussed.

RESULTS

A total of 19 retrospective articles were identified and selected for review: 6 case series (31.6 %) and 13 reports of single cases (68.4 %). The 19 articles and our two additional cases added up to a total of 19 patients with spinal CAPNON and 22 patients with intracranial CAPNON. All patients were treated surgically. A follow-up was provided in 13 patients with spinal (68.4 %) and in 16 patients with intracranial CAPNON (72.7 %), respectively. The follow-up showed no signs of recurrence in 12 of 13 patients with spinal CAPNON (92.3 %) and in 15 of 16 patients with intracranial CAPNON (93.7 %). One-tailed Fisher's exact test revealed no significant difference between complete and incomplete resection in terms of disease recurrence (spinal: p = 0.6842; intracranial: p = 0.3749). Analysis of the literature did not reveal any deaths directly associated with CAPNON.

CONCLUSIONS

Calcifying pseudoneoplasms are rare benign lesions of the CNS of yet unknown origin. Because of the increasing number of reports, this clinical entity should be taken into consideration in the differential diagnosis of intracranial and intraspinal calcified lesions.

Emil Theodor Kocher--valve surgery for epilepsy

Emil Theodor Kocher (1841-1917) was a pioneering and versatile Swiss surgeon who played a decisive role in the surgical evolution on the threshold to the 20th century. Apart from conducting intense research and fostering the development of the surgical treatment of thyroid gland diseases (honored with a Nobel Prize in 1909), he remained a generalist and was active in orthopedic, genitourinary, and neurologic surgery. Even today, many surgical techniques and instruments are still named after him, thus providing evidence of his great impact. His neurosurgical ambitions included, in particular, cerebral and spinal trauma, the pathophysiology of elevated intracranial pressure, as well as etiological considerations and the operative treatment of epilepsy. This article aims to shed light on Kocher's work on epilepsy, published exclusively in German, and illustrates the development of his idea on valve surgery for recurrent general convulsions.

[Combination of two severe neurologic diseases--therapeutic dilemma with fatal outcome]

We present the case of a female patient with the combination of progressive cerebral sinus and venous thrombosis and unruptured intracranial aneurysm. Therapy of the symptomatic sinus thrombosis was initiated with heparin and endovascular occlusion of the aneurysm was planned within the next days. Before the coiling was performed fatal subarachnoid haemorrhage from the aneurysm occurred. The two dangerous neurologic diseases are presented and discussed with focus on symptomatology and therapeutic urgence.

[Cervicobrachialgia - an update under special consideration of the surgical management]

The classic cervicobrachialgia results acutely from cervical nerve root compression by disc herniation or subacutely by radicular compression after progressive spondylotic changes of the cervical spine. The clinical presentation includes local and radiating pain syndromes that can be accompanied by sensorimotor deficits. Besides the medical history and a targeted clinical examination, supplementary radiographic means should be undertaken to confirm diagnosis. If no urgent surgical indication exists, conservative therapy should be initiated. However, with varying results of conservative and surgical therapy, chronic impairment can occur.

Surgical treatment of unruptured intracranial aneurysms in a low-volume hospital--outcome and review of literature

BACKGROUND

The aim of this study was to evaluate surgical outcome of unruptured intracranial aneurysms (UIAs) in a low-volume hospital and compare the results with the recent literature.

METHODS

A retrospective review of all consecutive craniotomies for UIA from July 1999 through June 2009 was performed. Morbidity was defined as modified Rankin Scale (mRS) ≥ 3 and evaluated six weeks after surgery. Cognitive function was evaluated at rehabilitation-to-home discharge. A PubMed database search (2001-2011) seeking retrospective, single-center studies reporting on surgical outcome of UIAs was performed.

RESULTS

There were 47 procedures performed in 42 patients to treat 50 UIAs (mean of 5 annual craniotomies). The mean age was 54.7 ± 12.1 years and mean aneurysm size was 7.6 ± 4.0mm. Favorable outcome (mRS 0-2) at six weeks after surgery was achieved in 45 of 47 procedures (95.7%). Aneurysm size ≥ 12 mm was statistically significant related to adverse outcome defined as mRS change ≥ 1 (71% vs. 29%; p = 0.018). Five patients (10.6%) with favorable neurological outcome (mRS 2) presented with cognitive impairment at rehabilitation-to-home discharge. There was no significant difference in overall morbidity and mortality comparing low- and high-volume hospitals (4.0% vs. 4.8%; p = 0.85).

CONCLUSIONS

Low-volume hospitals may achieve good results for surgical treatment of UIAs. The results indicate that defining numeric operative volume thresholds is not feasible to guide centralization of aneurysm treatment.

[The lumbar disc herniation - management, clinical aspects and current recommendations]

Lumbar disc herniation has a high prevalence and strong social-medical impact. Patients suffer from lower back pain that radiates from the spine. Loss of sensation or paresis adds to the clinical picture. The diagnosis should be confirmed by imaging in patients considered for surgery. High remission rates initially warrant conservative treatment (adequate analgesia and physiotherapy) in many patients. If this treatment does not lead to significant alleviation within 5-8 weeks, surgery should be performed to reduce the risk of chronic nerve affection. Posterior interlaminar fenestration is the intervention primarily conducted for this diagnosis. A relapse in the same region occurs in up to 10% of patients after months through years, which sometimes necessitates a reoperation if symptoms are pertinent.

[Cerebral arteriovenous malformations: clinical aspects and treatment possibilities]

Cerebral arteriovenous malformations (AVM) are vascular lesions that occur either congenitally or arise in early childhood. AVM are characterised by arteriovenous shunts through a nidus of coiled and tortuous vascular connections that connect feeding arteries to draining veins. Generally, AVM become evident through intracranial haemorrhage in patients aged 20-40 years. Especially, in the young adult presenting with epileptic seizures or focal neurological deficits AVM needs to be considered as an important differential diagnosis. Treatment modalities for the occlusion of symptomatic AVM include microneurosurgery, endovascular embolisation, or radiosurgery. These can be performed each on its own or in combination with the others. Incidentally diagnosed AVM require a thorough and individual consideration of treatment indications. This review deals with the current recommendations for the treatment of AVM in the adult patient.

[Intracerebral haemorrhage - when is a surgical treatment reasonable?]

Intracerebral haemorrhages (ICH) are responsible for 10-17% of all strokes and are associated with a high mortality and morbidity. More than 50% of the primary cases of ICH are associated with an underlying arterial hypertension and up to 30% with a cerebral amyloidosis. In supratentorial ICH, primary treatment generally should be conservative, as clinical studies could not show favourable outcomes after surgical haematoma evacuation. However, in patients with infratentorial haemorrhages and neurologic deterioration, early surgical evacuation should be considered. Modern therapeutic strategies and the focus of current and recent clinical research include early haemostasis, improvement of intensive care, and less invasive neurosurgical interventions, with the aim to reduce secondary brain damage. This review provides an overview of the clinical presentation of ICH and includes up-to-date recommendations concerning diagnostic and therapeutic options.

[Adult syringomyelia - a syndrome of different origins]

Syringomyelia describes an intra-medullary cyst in the spinal cord. In the adult patient, the pathology mostly results from Chiari-I-malformation or from severe spinal trauma. The clinical picture varies broadly, but symptoms often include pain and progressive neurologic deficits. During the clinical course, muscular atrophy and loss of pain and temperature sensation may develop in the affected region. Today, magnet resonance imaging helps to detect syringomyelia at an early stage. The interdisciplinary therapeutic approach includes an adequate pain treatment and physiotherapy, in selected cases a surgical intervention by an experienced surgeon. If not treated surgically, most symptomatic patients experience progressive neurologic deficits that may lead to severe paragplegia and chronic neuropathic pain.

[An uncommon reason for facial hypoesthesia]

A 58-year-old female admitted herself to the emergency department with progressive left-sided facial hypoesthesia. Magnetic resonance imaging revealed a 20 mm-sized aneurysm of the left vertebral artery leading to compression of the trigeminal nerve. An endovascular occlusion with a combined coiling and flow-diverter was performed. The left posterior inferior cerebellar artery (PICA) arised from the aneurysmal sac. Despite an extensive infarction of the left PICA-territory, the patient convalesced well and presented completely independent and without symptoms at the 4-week follow-up.

[The intracranial meningioma - therapeutic possibilities and limitations]

Meningiomas are common intracranial tumours that arise from arachnoidal cells. Clinically they often manifest by headache, focal or generalized seizures, or neurologic deficits as a result of brain compression. More than 90 percent of these mostly slow growing meningiomas are benign. In symptomatic patients a resection should be performed with the intention to cure or at least alleviate symptoms. In cases of subtotal resection an adjuvant radiotherapy should be deliberated. Stereotactic radiotherapy as initial treatment is an effective alternative for meningiomas, especially in patients not suitable for surgery due to various reasons. In patients that are refractory to treatment or with unresectable disease a hormonal- or chemotherapy can be considered.

[Craniopharyngioma--a "geographical malignant" tumour]

The craniopharyngioma is a rare dysontogenetic tumour that originates from either scattered cells of the craniopharyngeal duct or from metaplastically mutated anterior pituitary parenchyma cells. Despite being classified as a WHO-Class-I tumour, the histologically benign craniopharyngioma may display an aggressive behaviour. Like other congenital tumours, it usually becomes manifest within the first two decades of life. Patients typically complain of headache and a chiasma syndrome with bitemporal hemianopsy may develop depending on tumour localisation. In children, anterior pituitary insufficiency often manifests as growth restriction. Additionally, diabetes insipidus and other hormonal disturbances may develop. Therapeutically either radical total removal or subtotal resection in combination with postoperative radiation is recommended. In cystic tumors, stereotactic cyst drainage and adjuvant radiation may be a possible alternative. The prognosis is best in patients who are diagnosed early.

[Aneurysmal subarachonid haemorrhage]

The most characteristic symptom of an aneurysmal subarachnoid haemorrhage (aSAH) is a sudden onset of severe headache, which can be accompanied by meningism, impaired consciousness, and vegetative symptoms. A cerebral CT scan is the initial diagnostic tool of choice if aSAH is suspected. The localisation and morphology of the aneurysm is depicted in a CT-angiography and/or conventional panangiography. Until definitive exclusion of the aneurysm by either microsurgical clipping or endovascular coiling, rebleeding should be avoided implicitly. The postoperative phase, especially in patients with severe aSAH is embossed with the occurrence of disease-specific complications (cerebral vasospasm, intracranial hypertension, seizure disorder, hydrocephalus) and consecutively increased risk for secondary brain injury. Furthermore, many patients present systemic complications such as electrolyte disturbances and cardiac dysfunctions. Early identification and therapy of cerebral and systemic complications are very important in order improve functional outcome.

[Pott's puffy tumor - severe course of a sinusitis]

The disease pattern <<Pott's puffy tumour>> describes a local frontal-bone osteomyelitis that arises from an external infection with consecutive sub-periostal expansion. Symptoms may develop slowly or not at all with a mostly indolent protuberance on the patient's forehead. Symptomatic illness often indicates secondary morbidities. Here, we present a complicated case with intracranial dissemination.

[Trigeminal neuralgia - pathophysiology, clinical aspects and treatment]

The trigeminal neuralgia is characterised by paroxysmal appearing fulgurous stabbing pain. Its medical condition is caused through a local-circumscribed demyelinisation of the trigeminal nerve with consecutive conduction of salting impulses on afferent pain fibres. It is essential to differentiate the symptomatic from the idiopathic trigeminal neuralgia. As primary management, a pharmacological treatment with anticonvulsants is recommended in order to attenuate the ectopic-generated pain impulses. Different neurosurgical procedures are available in cases of resistance to therapy. Thereby, causal surgery in form of microvascular decompression is not only the operative treatment of choice, but because of the excellent results also a fundamental support of the theory of vascular compression. A comprehensive knowledge about diagnosis and management of trigeminal neuralgia is essential to treat patients efficiently and successfully. This synopsis summarises the current recommendations concerning diagnostics and therapeutic options.