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1.  Cranioplasty with autologous cryopreserved bone after decompressive craniectomy. Complications and risk factors for developing surgical site infection 
Acta Neurochirurgica  2014;156:805-811.
Background
Renewed interest has developed in decompressive craniectomy, and improved survival is shown when this treatment is used after malignant middle cerebral artery infarction. The aim of this study was to investigate the frequency and possible risk factors for developing surgical site infection (SSI) after delayed cranioplasty using autologous, cryopreserved bone.
Methods
This retrospective study included 74 consecutive patients treated with decompressive craniectomy during the time period May 1998 to October 2010 for various non-traumatic conditions causing increased intracranial pressure due to brain swelling. Complications were registered and patient data was analyzed in a search for predictive factors.
Results
Fifty out of the 74 patients (67.6 %) survived and underwent delayed cranioplasty. Of these, 47 were eligible for analysis. Six patients (12.8 %) developed SSI following the replacement of autologous cryopreserved bone, whereas bone resorption occurred in two patients (4.3 %). No factors predicted a statistically significant rate of SSI, however, prolonged procedural time and cardiovascular comorbidity tended to increase the risk of SSI.
Conclusions
SSI and bone flap resorption are the most frequent complications associated with the reimplantation of autologous cryopreserved bone after decompressive craniectomy. Prolonged procedural time and cardiovascular comorbidity tend to increase the risk of SSI.
doi:10.1007/s00701-013-1992-6
PMCID: PMC3956933  PMID: 24493001
Cranioplasty; Craniectomy; Autologous; Cryopreserved; Surgical site infection; Complications
2.  Patients’ anxiety around incidental brain tumors: a qualitative study 
Acta Neurochirurgica  2013;156:375-381.
Background
Incidental findings are common on MRI. Our study examined how patients are told about their incidental finding as well as anxiety until the neurosurgical consultation and afterward.
Methods
Qualitative research methodology was used. Thirty-two participants were interviewed using open-ended questions. Answers were transcribed and analyzed for themes.
Results
The level of patient satisfaction for the initial breaking of the news averaged 4.1 (range 1–5). Four themes were identified: (1) emotional stress over incidental findings are partially dependent on how the news was communicated; (2) breaking worrisome news is best done in person, but telephone communication can sometimes be acceptable; (3) patients are divided about how much information they wish to get about incidental findings before going for an MRI; (4) waiting for the neurosurgical consultation is a stressful time without adequate support.
Conclusions
When dealing with an unexpected MRI finding, patients are anxious about the situation. Our study exposes ways the experience could be made more comfortable for patients right from the start, from being told the news in a calm and sympathetic manner, to providing support for patients while they wait for a meeting with a neurosurgeon, to expediting the neurosurgical consultation.
doi:10.1007/s00701-013-1935-2
PMCID: PMC3898365  PMID: 24272523
Incidental findings; Brain MRI; Neurosurgery; Qualitative; Worrisome news
3.  Influence of variation in the catechol-O-methyltransferase gene on the clinical outcome after lumbar spine surgery for one-level symptomatic disc disease: a report on 176 cases 
Acta Neurochirurgica  2013;156:245-252.
Background
This study was aimed at the evaluation of the relationship between genetic polymorphisms of catechol-O-methyltransferase (COMT) (rs4680:A > G—Val158Met, rs6269:A > G, rs4633:C > T, rs4818:C > G) and pain sensitivity after lumbar discectomy.
Methods
All patients had one-level symptomatic disc herniation from L3 to S1. The primary data recorded included visual analogue pain scales assessing back and leg pain, Oswestry Disability Questionnaire assessing quality of life and pain intensity, received/filled pre- and postoperatively. Each subject was genotyped for single-nucleotide polymorphism in the COMT gene. Clinical outcome was measured by difference between pre- and postoperative values and those results were analyzed with genetics findings.
Results
Pain intensity was associated with the COMT polymorphism. Carriers of rs6269 AA, rs4633 TT, rs4818 CC, and rs4680 AA genotypes were characterized by the lowest preoperative scores related to pain intensity and lower pain intensity at 1 year after the surgery. The rs4633 CC, rs4680 GG genotypes demonstrated significant clinical improvement in VASBACK score at 1 year after the surgery. Patients with COMT haplotype associated with low metabolic activity of enzyme (A_C_C_G) showed better clinical outcome measured by ODI score and VASBACK score 1 year after surgery. We did not observe any significant correlation between leg pain and single-nucleotide polymorphisms in the COMT gene.
Conclusions
The results of our study indicate that polymorphism in the COMT gene may play an important role in the mechanism of pain perception, which may have a potential implication for clinical decision-making in the future.
doi:10.1007/s00701-013-1895-6
PMCID: PMC3898361  PMID: 24178190
COMT; Lumbar discectomy; Clinical outcome; Genetic variations; Lumbar disk herniation; Pain
4.  Anatomical variation of superior petrosal vein and its management during surgery for cerebellopontine angle meningiomas 
Acta Neurochirurgica  2013;155:1871-1878.
No systematic study is yet available that focuses on the surgical anatomy of the superior petrosal vein and its significance during surgery for cerebellopontine angle meningiomas. The aim of the present study was to examine the variation of the superior petrosal vein via the retrosigmoid suboccipital approach in relation to the tumor attachment of cerebellopontine angle meningiomas as well as postoperative complications related to venous occlusion. Forty-three patients with cerebellopontine angle meningiomas were analyzed retrospectively. Based on the operative findings, the tumors were classified into four subtypes: the petroclival type, tentorial type, anterior petrous type, and posterior petrous type. According to a previous anatomical report, the superior petrosal veins were divided into three groups: Type I which emptied into the superior petrosal sinus above and lateral to the internal acoustic meatus, Type II which emptied between the lateral limit of the trigeminal nerve at Meckel’s cave and the medial limit of the facial nerve at the internal acoustic meatus, and Type III which emptied into the superior petrosal sinus above and medial to Meckel’s cave. In both the petroclival and anterior petrous types, the most common vein was Type III which is the ideal vein for a retrosigmoid approach. In contrast, the Type II vein which is at high risk of being sacrificed during a suprameatal approach procedure was most frequent in posterior petrous type, in which the superior petrosal vein was not largely an obstacle. Intraoperative sacrificing of veins was associated with a significantly higher rate of venous-related phenomena, while venous complications occurred even in cases where the superior petrosal vein was absent or compressed by the tumor. The variation in the superior petrosal vein appeared to differ among the tumor attachment subtypes, which could permit a satisfactory surgical exposure without dividing the superior petrosal vein. In cases where the superior petrosal vein was previously occluded, other bridging veins could correspond with implications for the crucial venous drainage system, and should thus be identified and protected whenever possible.
doi:10.1007/s00701-013-1840-8
PMCID: PMC3779012  PMID: 23990034
Attachment; Classification; Cerebellopontine angle; Meningioma; Petrosal vein; Venous complication
5.  Fluorescein for vascular and oncological neurosurgery 
Acta Neurochirurgica  2013;155(8):1477-1478.
doi:10.1007/s00701-013-1778-x
PMCID: PMC3719004  PMID: 23793965
6.  Complex middle cerebral artery aneurysms: a new classification based on the angioarchitecture and surgical strategies 
Acta Neurochirurgica  2013;155(8):1481-1491.
Background
Because of the diversity of aneurysm morphology, complicated arterial anatomy and hemodynamic characteristics, tailored surgical treatments are required for cases of individual complex middle cerebral artery (MCA) aneurysms.
Methods
During an 8-year period, 59 complex MCA aneurysms in 58 patients were treated microsurgically in our department. Complex aneurysms were defined as having large (10–24 mm in diameter) or giant (diameter ≥ 25 mm) size or non-saccular morphology (fusiform, dissecting or serpentine).
Results
Direct clipping of the aneurysmal necks was achieved in eight patients, while reconstructive clipping was performed in 25 patients. Indirect aneurysm occlusion was performed in 25 cases, including trapping or resecting the aneurysm in four cases, trapping or resecting the aneurysm with extra-intracranial (EC) or intra-intracranial (IC) bypass in 21 cases and internal carotid artery (ICA) sacrifice with EC-IC bypass in one case. Forty-eight aneurysms (81.4 %) were completely obliterated. Graft patency was confirmed in 20 of 21 cases (95.2 %) with bypass. A recurrent aneurysm was detected in one case and a re-operation was performed. Two patients with Hunt-Hess grade IV aneurysms died during the perioperative period. Overall, 52 cases (88.1 %) had good outcomes (Glasgow Outcome Scale ≥ 4) during the late follow-up period.
Conclusion
The surgical modality and strategy for treating complex MCA aneurysm are decided according to the morphology of the aneurysm, vascular anatomy and the hemodynamic characteristics of each case. Thus, we developed a new classification based on the angioarchitecture. Favorable outcomes can be achieved by treating complex MCA aneurysms with appropriate surgical modalities, strategies and techniques.
doi:10.1007/s00701-013-1751-8
PMCID: PMC3718994  PMID: 23715946
Middle cerebral artery; Complex aneurysm; Bypass surgery; Clipping
7.  Impact of anterior clinoidectomy on visual function after resection of meningiomas in and around the optic canal 
Acta Neurochirurgica  2013;155(7):1293-1299.
Background
Meningiomas of the anterior and middle skull base frequently involve the optic nerve and cause progressive visual impairment. Surgical decompression of the optic nerve is the only option to preserve visual function. Depending on the invaded structures, optic nerve decompression can be part of a complete tumor removal or the main surgical intention in terms of local debulking. However, bony decompression of the optic canal including anterior clinoidectomy for optic nerve decompression is still a surgical maneuver under discussion.
Methods
From 2006 to 2011, 46 consecutive patients with skull base meningiomas in and around the optic canal were operated. The pterional approach was tailored for each patient. Resection included bony decompression of the optic canal with or without anterior clinoidectomy. Visual acuity and fields were evaluated pre- and postoperatively.
Results
Fifty-three percent of patients underwent anterior clinoidectomy, 23 % optic canal unroofing, and 24 % any bony decompression. In 21 patients (46 %), gross total resection (GTR, Simpson grade I or II) was achieved, while 25 patients (54 %) received subtotal resection (STR, Simpson grade III or IV). Sixty-three percent of patients presented with preoperative visual impairment. Postoperative visual changes were significantly related to preoperative visual function. While all patients with normal preoperative vision remained unchanged, in patients with impaired vision, surgery caused improvement in 70 % and deterioration in 10 % of patients (p < 0.0001). In patients with anterior clinoidectomy, vision improved more frequently than without anterior clinoidectomy (p < 0.05).
Conclusions
Anterior clinoidectomy is safe and may improve visual outcome in meningiomas in and around the optic canal.
doi:10.1007/s00701-013-1741-x
PMCID: PMC3683144  PMID: 23665725
Anterior clinoid process; Optic nerve; Visual function; Skull base; Meningioma
8.  Operative field temperature during transnasal endoscopic cranial base procedures 
Acta Neurochirurgica  2013;155(5):903-908.
Background
Data regarding the safety of endoscopic skull base exploration are very scarce. With this method, fragile vital structures (cranial nerves, the optic complex, brainstem, hypothalamus or cerebral ventricles) are exposed to direct illumination within a closed space. Also, high-speed drills, cauterization and ultrasonic aspiration deliver a significant load of thermal energy. The aim of this study was to record the temperature close to the structures of the skull base and in the intradural space during the procedures performed using extended endoscopic transnasal approaches.
Methods
The temperature of the skull base was continuously recorded during six transnasal endoscopic procedures. Implantable copper-constantan thermocouples were inserted: one into the esophagus and another through the nostril to reach the operative field at the skull base.
Results
At the beginning of the procedure, the temperature of the operative field was on average 36.8 °C ± 0.80 °C, i.e. only 1 °C higher than the esophageal temperature. Then it grew continuously during the whole procedure, to eventually reach a level of 42–43 °C at the final stage, whereas the esophageal temperature remained stable. Occasionally, the temperature increased up to 45 °C during cauterization and ultrasonic aspiration, and even up to 62 °C during high-speed drilling.
Conclusion
Endoscopic skull base surgery is associated with an incessant increase of the temperature of the intraoperative field. The temperature can peak suddenly to levels which can potentially harm neural structures and influence the rate of postoperative complications.
doi:10.1007/s00701-013-1674-4
PMCID: PMC3627044  PMID: 23494137
Endoscopy; Transnasal; Extended approach; Cranial base; Temperature
9.  Ultrasound imaging in neurosurgery: approaches to minimize surgically induced image artefacts for improved resection control 
Acta Neurochirurgica  2013;155(6):973-980.
Background
Intraoperative ultrasound imaging is used in brain tumor surgery to identify tumor remnants. The ultrasound images may in some cases be more difficult to interpret in the later stages of the operation than in the beginning of the operation. The aim of this paper is to explain the causes of surgically induced ultrasound artefacts and how they can be recognized and reduced.
Methods
The theoretical reasons for artefacts are addressed and the impact of surgery is discussed. Different setups for ultrasound acquisition and different acoustic coupling fluids to fill up the resection cavity are evaluated with respect to improved image quality.
Results
The enhancement artefact caused by differences in attenuation of the resection cavity fluid and the surrounding brain is the most dominating surgically induced ultrasound artefact. The influence of the artefact may be reduced by inserting ultrasound probes with small footprint into the resection cavity for a close-up view of the areas with suspected tumor remnants. A novel acoustic coupling fluid developed for use during ultrasound imaging in brain tumor surgery has the potential to reduce surgically induced ultrasound artefacts to a minimum.
Conclusions
Surgeons should be aware of artefacts in ultrasound images that may occur during brain tumor surgery. Techniques to identify and reduce image artefacts are useful and should be known to users of ultrasound in brain tumor surgery.
doi:10.1007/s00701-013-1647-7
PMCID: PMC3656245  PMID: 23459867
Ultrasound; Neurosurgery; Brain tumors; Resection control; Ultrasound artefacts; Enhancement artefact; Ultrasonography; Intraoperative imaging
10.  Proteins involved in regulating bone invasion in skull base meningiomas 
Acta Neurochirurgica  2012;155(3):421-427.
Background
Bone invasive skull base meningiomas are a subset of meningiomas that present a unique clinical challenge due to brain and neural structure involvement and limitations in complete surgical resection, resulting in higher recurrence and need for repeat surgery. To date, the pathogenesis of meningioma bone invasion has not been investigated. We investigated immunoexpression of proteins implicated in bone invasion in other tumor types to establish their involvement in meningioma bone invasion.
Methods
Retrospective review of our database identified bone invasive meningiomas operated on at our institution over the past 20 years. Using high-throughput tissue microarray (TMA), we established the expression profile of osteopontin (OPN), matrix metalloproteinase-2 (MMP2), and integrin beta-1 (ITGB1). Differential expression in tumor cell and vasculature was evaluated and comparisons were made between meningioma anatomical locations.
Results
MMP2, OPN, and ITGB1 immunoreactivity was cytoplasmic in tumor and/or endothelial cells. Noninvasive transbasal meningiomas exhibited higher vascular endothelial cell MMP2 immunoexpression compared to invasive meningiomas. We found higher expression levels of OPN and ITGB1 in bone invasive transbasal compared to noninvasive meningiomas. Strong vascular ITGB1 expression extending from the endothelium through the media and into the adventitia was found in a subset of meningiomas.
Conclusions
We have demonstrated that key proteins are differentially expressed in bone invasive meningiomas and that the anatomical location of bone invasion is a key determinant of expression pattern of MMP1, OPN, and ITGB1. This data provides initial insights into the pathophysiology of bone invasion in meningiomas and identifies factors that can be pursued as potential therapeutic targets.
doi:10.1007/s00701-012-1577-9
PMCID: PMC3569595  PMID: 23238945
Bone invasion; Integrins; Matrix metalloproteinase; Meningioma; Osteopontin; Transbasal meningioma
11.  Volume and densities of chronic subdural haematoma obtained from CT imaging as predictors of postoperative recurrence: a prospective study of 107 operated patients 
Acta Neurochirurgica  2012;155(2):323-333.
Background
Chronic subdural haematoma (CSDH) is a common entity in neurosurgery with a considerable postoperative recurrence rate. Computerised tomography (CT) scanning remains the most important diagnostic test for this disorder. The aim of this study was to characterise the relationship between the recurrence of CSDH after treatment with burr-hole irrigation and closed-system drainage technique and CT scan features of these lesions to assess whether CT findings can be used to predict recurrence.
Methods
We investigated preoperative and postoperative CT scan features and recurrence rate of 107 consecutive adult surgical cases of CSDH and assessed any relationship with univariate and multivariate regression analyses.
Results
Seventeen patients (15.9 %) experienced recurrence of CSDH. The preoperative haematoma volume, the isodense, hyperdense, laminar and separated CT densities and the residual total haematoma cavity volume on the 1st postoperative day after removal of the drainage were identified as radiological predictors of recurrence. If the preoperative haematoma volume was under 115 ml and the residual total haematoma cavity volume postoperatively was under 80 ml, the probability of no recurrence was very high (94.4 % and 97.4 % respectively).
Conclusions
These findings from CT imaging may help to identify patients at risk for postoperative recurrence.
doi:10.1007/s00701-012-1565-0
PMCID: PMC3552365  PMID: 23229873
Chronic subdural haematoma; Computerised tomography; Densities; Multiple regression; Recurrence; Volume
13.  Diagnosis and surgical strategy for sacral meningeal cysts with check-valve mechanism: technical note 
Acta Neurochirurgica  2012;155(2):309-313.
Objective
There is agreement that symptomatic sacral meningeal cysts with a check-valve mechanism and/or large cysts representing space-occupying lesions should be treated surgically. This study investigated factors indicating a need for surgical intervention and surgical techniques for sacral meningeal cysts with a check-valve mechanism.
Methods
In ten patients presenting with sciatica and neurological deficits, myelography, computed tomography (CT) myelography, and magnetic resonance imaging (MR imaging) detected sacral meningeal cysts with a check-valve mechanism. One patient had two primary cysts. Ten cysts were type 2 and one cyst was type 1. Nine of the ten patients had not undergone previous surgery, while the remaining case involved recurrent cyst. For the seven patients with normal (i.e., not huge or recurrent) type 2 cysts and no previous surgery (eight cysts), suture after collapse of the cyst wall was performed. For the recurrent type 2 cyst, duraplasty and suture with collapse of the cyst wall were performed to eliminate the check-valve mechanism. For the remaining type 2 cyst, a primary root was sacrificed because of the huge size of the cyst. For the type 1 cyst, the neck of the cyst was ligated.
Results
In all cases, chief complaints disappeared immediately postoperatively and no deterioration of clinical symptoms has been seen after a mean follow-up of 27 months.
Conclusions
The presence or absence of a check-valve mechanism is very important in determining the need for surgical intervention for sacral meningeal cysts.
doi:10.1007/s00701-012-1550-7
PMCID: PMC3552371  PMID: 23160631
Sacral meningeal cyst; Check-valve mechanism; Surgical strategy
14.  Incomplete tumour control following DNA vaccination against rat gliomas expressing a model antigen 
Acta Neurochirurgica  2012;155(1):51-59.
Background
Vaccination against tumour-associated antigens is one approach to elicit anti-tumour responses. We investigated the effect of polynucleotide (DNA) vaccination using a model antigen (E. coli lacZ) in a syngeneic gliosarcoma model (9L).
Methods
Fisher 344 rats were vaccinated thrice by intramuscular injection of a lacZ-encoding or a control plasmid in weekly intervals. One week after the last vaccination, lacZ-expressing 9L cells were implanted into the striatum.
Results
After 3 weeks, in lacZ-vaccinated animals the tumours were significantly smaller than in control-vaccinated animals. In cytotoxic T cell assays lysis rates of >50 % could only be observed in a few of the lacZ-vaccinated animals. This response was directed against lacZ-expressing and parental 9L cells but not against syngeneic MADB 106 adenocarcinoma cells. In Elispot assays interferon-γ production was observed upon stimulation with 9LlacZ and 9L wild-type but not MADB 106 cells. This response was higher for lacZ-immunized animals. All animals revealed dense infiltrates with CD8+ lymphocytes and, to a lesser extent, with NK cells. CD25-staining indicated cells possibly associated with the maintenance of peripheral tolerance to self-antigens. All tumours were densely infiltrated by microglia consisting mostly of ramified cells. Only focal accumulation of macrophage-like cells expressing ED1, a marker for phagocytic activity, was observed.
Conclusion
Prophylactic DNA vaccination resulted in effective but incomplete suppression of brain tumour formation. Mechanisms other than cytotoxic T cell responses as measured in the generally used in vitro assays appear to play a role in tumour suppression.
doi:10.1007/s00701-012-1526-7
PMCID: PMC3535398  PMID: 23132370
DNA vaccination; Immunotherapy; Rat glioma; lacZ
15.  The relationship between Cho/NAA and glioma metabolism: implementation for margin delineation of cerebral gliomas 
Acta Neurochirurgica  2012;154(8):1361-1370.
Background
The marginal delineation of gliomas cannot be defined by conventional imaging due to their infiltrative growth pattern. Here we investigate the relationship between changes in glioma metabolism by proton magnetic resonance spectroscopic imaging (1H-MRSI) and histopathological findings in order to determine an optimal threshold value of choline/N-acetyl-aspartate (Cho/NAA) that can be used to define the extent of glioma spread.
Method
Eighteen patients with different grades of glioma were examined using 1H-MRSI. Needle biopsies were performed under the guidance of neuronavigation prior to craniotomy. Intraoperative magnetic resonance imaging (MRI) was performed to evaluate the accuracy of sampling. Haematoxylin and eosin, and immunohistochemical staining with IDH1, MIB-1, p53, CD34 and glial fibrillary acidic protein (GFAP) antibodies were performed on all samples. Logistic regression analysis was used to determine the relationship between Cho/NAA and MIB-1, p53, CD34, and the degree of tumour infiltration. The clinical threshold ratio distinguishing tumour tissue in high-grade (grades III and IV) glioma (HGG) and low-grade (grade II) glioma (LGG) was calculated.
Results
In HGG, higher Cho/NAA ratios were associated with a greater probability of higher MIB-1 counts, stronger CD34 expression, and tumour infiltration. Ratio threshold values of 0.5, 1.0, 1.5 and 2.0 appeared to predict the specimens containing the tumour with respective probabilities of 0.38, 0.60, 0.79, 0.90 in HGG and 0.16, 0.39, 0.67, 0.87 in LGG.
Conclusions
HGG and LGG exhibit different spectroscopic patterns. Using 1H-MRSI to guide the extent of resection has the potential to improve the clinical outcome of glioma surgery.
doi:10.1007/s00701-012-1418-x
PMCID: PMC3407558  PMID: 22729482
Cho/NAA; Glioma boundary; 1H-MRSI; Tumour infiltration; Needle biopsy; Metabolism
16.  Spinal cord herniation: management and outcome 
Acta Neurochirurgica  2012;154(7):1249-1250.
doi:10.1007/s00701-012-1365-6
PMCID: PMC3382638  PMID: 22588337
17.  Clinical outcome of instrumented fusion for the treatment of failed back surgery syndrome: a case series of 100 patients 
Acta Neurochirurgica  2012;154(7):1213-1217.
Object
Failed back surgery syndrome is defined as persistent chronic low-back pain and/or leg pain lasting more than 1 year, despite of one or more surgical procedures. Instrumented spinal fusion has been offered by surgeons as a potential treatment to recover from pain and functional disability. Factors contributing to good outcome of instrumented spinal fusion have not been investigated extensively. This study evaluated the global perceived recovery and functional status of patients after instrumented fusion for the treatment of failed back surgery syndrome.
Methods
Between January 2004 and September 2007, 100 patients underwent instrumented spinal fusion because of persistent back and/or leg pain lasting more than 1 year despite of one or more previous spine surgeries. The global perceived recovery of the patients was documented on a seven-point Likert scale, in which good outcome was defined as “complete recovery” and “almost complete recovery”. Pain was evaluated by the 100-mm visual analogue scale (VAS) of back pain and leg pain, and functional disability measured by the Roland Disability Questionnaire for Sciatica (RDQ) and Oswestry Disability Index (ODI). The Hospital Anxiety and Depression Scale (HADS) evaluated psychological co-morbidity. All patients were sent questionnaires by mail. Pearson’s correlation coefficient was calculated between outcome measures and preoperative patient characteristics.
Results
Eighty-two patients (82% response rate) returned questionnaires that were useful for analysis. After a mean follow-up period of 15 months, 35% of the patients reported good outcome, whereas 65% had unsatisfactory outcome. The mean (± SD) score of VAS low-back pain and leg pain was 45.7 ± 29 and 37.9 ± 31.9, respectively. The mean (± SD) RDQ and ODI score was 11.8 ± 5.4 and 30.6 ± 20.3, respectively. HADS score indicated a possible anxiety disorder in 28% of the patients and in 30% a possible underlying depression. Of the patients’ baseline characteristics, there was only a significantly negative correlation between level of education and outcome.
Conclusions
The present study showed disappointing outcome of instrumented fusion for the treatment of failed back surgery syndrome in terms of perceived recovery, functional disability and pain. Conservative management is probably more beneficial and, therefore, more selective and careful assessment should be done in order to prevent unnecessary surgery.
doi:10.1007/s00701-012-1380-7
PMCID: PMC3382643  PMID: 22588339
Failed back surgery syndrome; Instrumented fusion; Pain; Postlaminectomy syndrome; Surgery
18.  Gamma knife surgery for brain metastases from ovarian cancer 
Acta Neurochirurgica  2012;154(9):1669-1677.
Background
Brain metastases from ovarian cancer are rare, but their incidence is increasing. The purpose of this study was to investigate the characteristics of brain metastases from ovarian cancer, and to assess the efficacy of treatment with gamma knife surgery (GKS).
Methods
A retrospective review was performed of patients with brain metastases from ovarian cancer who were treated at the Tokyo Gamma Unit Center from 2006 to 2010.
Results
Sixteen patients were identified. Their median age at diagnosis of brain metastases was 56.5 years, the median interval from diagnosis of ovarian cancer to brain metastases was 27.5 months, and the median number of brain metastases was 2. The median Karnofsky Performance Score (KPS) at the first GKS was 80. The median survival following diagnosis of brain metastases was 12.5 months, and 6-month and 1-year survival rates were 75 % and 50 %, respectively. The tumor control rate was 86.4 %. The KPS (<80 vs ≥80) and total volume of brain metastases (<10 cm3 vs ≥10 cm3) were significantly associated with survival according to a univariate analysis (p = 0.004 and p = 0.02, respectively).
Conclusions
The results of this study suggest that GKS is an effective remedy and acceptable choice for the control of brain metastases from ovarian cancer.
doi:10.1007/s00701-012-1376-3
PMCID: PMC3426666  PMID: 22588338
Ovarian cancer; Brain metastases; Gamma knife surgery; Tumor control rate
19.  Pituitary tumorous hyperplasia due to primary hypothyroidism 
Acta Neurochirurgica  2012;154(8):1489-1492.
Background
To study the diagnostic and therapeutic features of pituitary tumorous hyperplasia due to primary hypothyroidism.
Methods
Fifteen patients with pituitary tumorous hyperplasia were studied in clinical manifestation, pathologic, endocrinological, radiographic and therapeutic features retrospectively.
Results
All of these patients suffered from primary hypothyroidism. Magnetic resonance imaging (MRI) scanning found that there were masses in the sellar region with equal T1 and little longer T2 signal, and which could be obviously enhanced by gadolinium EDTA injection. Diameters of these masses were between 1.1 and 2.5 cm. Thyroxine substitution therapy was ordered. Four months later, MRI scanning found that the masses disappeared and only normal pituitary gland left. Plasma thyroxine, thyroid-stimulating hormone (TSH), and prolactin (PRL) levels dropped to their normal ranges.
Conclusions
Thyroxine substitution therapy was the first choice of pituitary tumorous hyperplasia due to primary hypothyroidism. If they are followed by TSH adenoma, or the optic chiasma was pressed by the enlarged pituitary, transsphenoidal microsurgery could be applied.
doi:10.1007/s00701-012-1342-0
PMCID: PMC3407554  PMID: 22527578
Hypothyroidism; Pituitary; Tumorous hyperplasia
20.  A case of late-onset multiple sclerosis mimicking glioblastoma and displaying intraoperative 5-aminolevulinic acid fluorescence 
Acta Neurochirurgica  2012;154(5):899-901.
doi:10.1007/s00701-012-1319-z
PMCID: PMC3337409  PMID: 22402878
Medicine & Public Health; Neurosurgery; Surgical Orthopedics; Interventional Radiology; Minimally Invasive Surgery; Neurology; Neuroradiology
21.  5-Aminolevulinic acid-induced protoporphyrin IX fluorescence as immediate intraoperative indicator to improve the safety of malignant or high-grade brain tumor diagnosis in frameless stereotactic biopsies 
Acta Neurochirurgica  2012;154(4):585-588.
Background
Frameless stereotactic biopsies are replacing frame-based stereotaxy as a diagnostic approach to brain lesions. In order to avoid a sampling bias or negative histology, multiple specimens are often taken. This in turn increases the risk of hemorrhagic complications.
Objective
We present the use of 5-aminolevulinic acid (5-ALA)-induced protoporphyrin IX fluorescence in frameless stereotaxy to improve the procedure duration and yield, and thereby reduce the risk of complications.
Methods
Patients with suspected high-grade brain tumors are given 5-ALA 4 h prior to stereotactic biopsy. The biopsy needle is guided to the target using frameless stereotaxy based either on preoperative images or combined with intraoperative MRI sequences. The specimen is illuminated with blue light to look for fluorescence. In case of a positive fluorescence within the tissue sample, no frozen sections are obtained, and no further specimens are taken.
Results
The samples of 13 patients revealed a positive fluorescence and were histologically confirmed as malignant or high-grade brain neoplasms. four cases were fluorescence-negative, requiring frozen section confirmation and/or multiple samples. In theses cases histology was either nonspecific gliotic changes or low-grade tumors. There were no complications related to the additional use of 5-ALA.
Conclusion
5-ALA fluorescence in stereotactic biopsies can increase the safety and accuracy of these procedures by reducing sampling errors and eliminating the need for multiple samples and/or frozen section verification, creating a more accurate, faster and safer procedure for cases of suspected malignant or high-grade brain tumors situated in deep or eloquent areas.
doi:10.1007/s00701-012-1290-8
PMCID: PMC3308005  PMID: 22297399
5-Aminolevulinic acid; Protoporphyrin IX; Stereotactic biopsy; Brain tumor; Fluorescence
22.  Side-to-side neurorrhaphy for high-level peripheral nerve injuries 
Acta Neurochirurgica  2012;154(3):527-532.
Background
The results of peripheral nerve repair, especially for high-level peripheral nerve injuries, have been unsatisfactory. The method of side-to-side neurorrhaphy was developed in our laboratory from 1994 to 2002. This method involves suturing the injured nerve to a nearby donor nerve in a side-to-side manner. This study was performed to assess the clinical results of side-to-side neurorrhaphy in patients with high-level peripheral nerve injuries.
Methods
Twenty-five patients with various types of high-level peripheral nerve injuries who underwent side-to-side neurorrhaphy were studied. The British Medical Research Council (BMRC) scale was used to assess recovery of nerve function.
Results
Average follow-up duration was 3.2 years. Before surgery the patients had a nerve function of M0/S0 to M1/S1. After side-to-side neurorrhaphy, 7 patients had a score of M3/S4, 8 patients a score of M3/S3 and 10 patients a score of M2/S3. The total useful recovery rate (BMRC grade ≥3) was 60% for motor function and 100% for sensory function. Side-to-side neurorrhaphy did not result in any significant loss of donor nerve function. There was significant correlation between both the type of injury and the time interval between injury and surgery and motor nerve function. Age, gender and location of the injured nerve did not correlate with sensory or motor nerve function.
Conclusion
Side-to-side neurorrhaphy appears to be promising as a feasible method for repair of high-level peripheral nerve injuries.
doi:10.1007/s00701-011-1264-2
PMCID: PMC3284681  PMID: 22231778
Nerve injury; Denervated muscles; Irreversible atrophy; Side-to-side neurorrhaphy; Nerve function
23.  Restenosis after microsurgical non-patch carotid endarterectomy in 586 patients 
Acta Neurochirurgica  2011;154(3):423-431.
Background
Carotid endarterectomy (CEA) reduces the risk of stroke in patients with symptomatic (>50%) and asymptomatic (>60%) carotid artery stenosis. Here we report the midterm results of a microsurgical non-patch technique and compare these findings to those in the literature.
Methods
From 1998 to 2009 we treated 586 consecutive patients with CEA. CEA was performed, under general anesthesia, with a surgical microscope using a non-patch technique. Somatosensory evoked potential and transcranial Doppler were continuously monitored. Cross-clamping was performed under EEG burst suppression and adaptive blood pressure increase. Follow-up was performed by an independent neurologist. Mortality at 30 days and morbidity such as major and minor stroke, peripheral nerve palsy, hematoma and cardiac complications were recorded. The restenosis rate was assessed using duplex sonography 1 year after surgery.
Results
A total of 439 (75%) patients had symptomatic and 147 (25%) asymptomatic stenosis; 49.7% of the stenoses were on the right-side. Major perioperative strokes occurred in five (0.9%) patients [n = 4 (0.9%) symptomatic; n = 1 (0.7%) asymptomatic patients]. Minor stroke was recorded in six (1%) patients [n = 4 (0.9%) symptomatic; n = 2 (1.3%) asymptomatic patients]. Two patients with symptomatic stenoses died within 1 month after surgery. Nine patients (1.5%) had reversible peripheral nerve palsies, and nine patients (1.5%) suffered a perioperative myocardial infarction. High-grade (>70%) restenosis at 1 year was observed in 19 (3.2%) patients [n = 12 (2.7%) symptomatic; n = 7 (4.7%) asymptomatic patients].
Conclusions
The midterm rate of restenosis was low when using a microscope-assisted non-patch endarterectomy technique. The 30-day morbidity and mortality rate was comparable or lower than those in recently published surgical series.
doi:10.1007/s00701-011-1233-9
PMCID: PMC3284671  PMID: 22113556
Carotid Stenosis; Asymptomatic; Symptomatic; Microsurgical; Non-patch; Restenosis
24.  Surgical clipping as the preferred treatment for aneurysms of the middle cerebral artery 
Acta Neurochirurgica  2011;153(11):2111-2117.
Objective
In recent years the endovascular treatment of intracranial aneurysms (coiling) has progressively gained recognition, particularly after the publication of the International Subarachnoid Aneurysm Trial (ISAT) in 2002. Despite the fact that in ISAT middle cerebral artery (MCA) aneurysms were clearly underrepresented, the study is often used as an argument to favor coiling above surgery in MCA aneurysms. Taken into account that MCA aneurysms are very well accessible for surgery, a contemporary assessment of the benefits of a preferred surgical strategy for MCA aneurysms was performed in a tertiary neurovascular referral center.
Methods
A prospectively kept single-center database of 151 consecutive patients with an MCA aneurysm was reviewed over a 6-year period (2001–2006). Long-term follow-up after surgical treatment of a ruptured MCA aneurysm was obtained in 74 out of 77 (96%) patients. The outcome was compared with relevant series in the literature.
Results
After a mean follow-up of 4.7 years, 59 out of 74 surgically treated patients (80%) with a ruptured MCA aneurysm had a good outcome (mRankin 0–2). All patients with an unruptured MCA aneurysm also had a good outcome after clipping. This is well-matched with the findings of the literature search, and competitive with the endovascular results.
Conclusion
Surgical clipping is recommended as the principal treatment strategy for MCA aneurysms. This is not only ethically defendable in view of the surgical results but also in line with a strategy to maintain surgical experience within centralized neurovascular centers.
doi:10.1007/s00701-011-1139-6
PMCID: PMC3197920  PMID: 21898188
Brain aneurysm; Middle cerebral artery; Subarachnoid hemorrhage; Endovascular coiling; Neurosurgical clipping
25.  Pituitary enlargement in spontaneous intracranial hypotension—a diagnostic pitfall 
Acta Neurochirurgica  2011;153(12):2445-2446.
doi:10.1007/s00701-011-1099-x
PMCID: PMC3217151  PMID: 21800104

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