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The objective of this study was to evaluate the morphology of glioblastoma on structural pretreatment magnetic resonance imaging (MRI), defining imaging prognostic factors. We conducted a retrospective analysis of MR images from 114 patients harboring a primary glioblastoma, derived from two neurosurgical departments. Tumor segmentation was carried out in a semi-automated fashion. Tumor compartments comprised contrast-enhancing volume (CEV+), perifocal hyperintensity on fluid-attenuated inversion recovery (FLAIR) images (FLAIR+) excluding CEV+, and a non-enhancing area within the CEV+ lesion (CEV−). Additionally, two ratios were calculated from these volumes, the edema-tumor ratio (ETR) and necrosis-tumor ratio (NTR). All patients received surgical resection, followed by concomitant radiation and chemotherapy. Tumor segmentation revealed the strongest correlation between the CEV+ volume and the CEV−, presenting intratumoral necrosis (p

Objective Previous research has shown a strong correlation between the Ki-67 proliferation index and grade of malignancy in astrocytoma. Ki-67 has also shown encouraging results as a prognostic marker for patients' overall survival (OS). We focus on whether the index is linked to the appearance of glioblastoma on pretreatment magnetic resonance imaging (MRI) or to OS. Methods In our retrospective study, only isocitrate dehydrogenase IDH wild-type glioblastoma was included (n = 152). Ki-67 index was quantified via immunohistochemistry. On all pretreatment MRI, tumor compartments (tumor, necrosis, and edema) were volumetrically assessed. An OS subpopulation was filtered from the total cohort (residual tumor volume ≤2 cm3). In addition, a propensity score matching was executed. Results All volumetric assessed tumor volumes correlated with each other (P ≤ 0.011), although the Ki-67 index showed no correlation with any of the measured volumes. Concerning the OS, a cutoff value of 20% for the Ki-67 index showed a significant influence on patients' OS in multivariate analysis (P = 0.043). Conclusions The unique appearance of every glioblastoma on MRI seems to be independent of the Ki-67 index. Furthermore, the Ki-67 index did show a distinct prognostic value for OS within our cohort at a cutoff value of 20% for Ki-67.

The potential impact of different radiological features of glioblastoma multiforme (GBM) on overall survival (OS) like tumor volume, peritumoral edema (PTE), necrosis volume, necrosis-tumor ratio (NTR) and edema-tumor ratio (ETR) is still very controversial. To determine the influence of volumetric data on OS und to compare different measuring techniques described in literature. We prospectively evaluated preoperative MR images from 30 patients harboring a primary supratentorial GBM. All patients received gross-total tumor resection followed by standard radiation and chemotherapy (temozolomide). By 3D semi-automated segmentation, we measured tumor volume, necrosis volume, PTE, postoperative residual tumor volume and calculated ETR, NTR and the extent of resection. After critical review of the existing literature we compared alternative measuring techniques with the gold standard of 3D segmentation. Statistical analysis showed a significant impact of the preoperative tumor and necrosis volumes on OS (p = 0.041, respectively p = 0.039). Furthermore, NTR also showed a significant association with OS (p = 0.005). Comparison of previously described measuring techniques and scorings with our results showed that no other technique is reliable and accurate enough as a predictive tool. The critical review of previously published studies revealed mainly inaccurate measurement techniques and patient selection as potential reasons for inconsistent results. Preoperatively measured necrosis volume and NTR are the most important radiological features of GBM with a strong influence on OS. No other measuring techniques are specific enough and comparable with 3D segmentation.

Das zunehmende Bestreben, Behandlungsablaufe stationarer Patienten effizienter zu gestalten, fuhrt zur zunehmenden Verkurzung der Krankenhausverweildauer und Minimierung der postoperativen Uberwachung. Vor diesem Hintergrund erschien es sinnvoll, das postoperative Komplikationsspektrum nach elektiven Eingriffen im eigenen Krankengut zu erfassen, im Hinblick auf seine intensivmedizinische Relevanz zu bewerten und das eigene Vorgehen mit dem Standard der postoperativen Versorgung derartiger Patienten in Deutschland zu vergleichen. Samtliche 499 elektiv kraniotomierte Patienten aus den Jahren 2010–2013, die in unserer Abteilung operiert wurden, konnten entsprechend verschiedener Behandlungskriterien (vaskulare Erkrankungen [Aneurysmen; arteriovenose Malformationen, AVM; Kavernome], supra- und infratentorielle Tumoren, transsphenoidal operierte Hypophysenadenome und stereotaktische Biopsien) eingeschlossen werden. Alle Komplikationen, gewichtet nach „minor“ und „major complications“, wurden wahrend der stationaren Behandlung erfasst. Des Weiteren wurden 155 neurochirurgische Kliniken und Abteilungen zu ihrer jeweiligen postoperativen Uberwachungsstrategie in den obigen Behandlungskategorien befragt. Die Anzahl der Komplikationen entsprach den allgemeinhin publizierten Daten, wenngleich „minor complications“ (13,4 % in unserem Kollektiv) sehr selten in der Literatur miterfasst werden, diese jedoch fur eine angemessene postoperative stationare Uberwachung sprechen. Die Umfrageergebnisse zeigen weiterhin eine v. a. intensivmedizinische Uberwachung von elektiv kraniotomierten Patienten in Deutschland. Der unbestrittene Standard der postoperativen Uberwachung elektiv operierter neurochirurgischer Patienten ist nach wie vor die Intensivstation. Obgleich flexiblere Uberwachungsmodalitaten zur Verfugung stehen, muss eine kostengetriebene Umstrukturierung der postoperativen Uberwachung und insbesondere der Verkurzung der Krankenhausverweildauer sehr genau gepruft werden.

BACKGROUND Seizures are a common initial symptom of malignant brain tumors such as glioblastoma (GBM). However, why some of these tumors are epileptogenic and others never trigger seizures remains controversial. OBJECTIVE To identify potential clinical and radiological features of epileptogenic tumors and the effect of initial seizures on survival. METHODS The analyzed patient cohort was retrospectively compiled (bicentric), only isocitrate dehydrogenase wild-type GBMs were included. Volumetric assessment was performed on pretreatment magnetic resonance imaging with the aid of a semi-automated 3D measurement (tumor, necrosis, and edema volume). Two ratios were calculated, reflecting the proportion of peritumoral edema and necrosis (NTR) toward the tumor volume. For overall survival analyses, only patients after a surgical resection (residual tumor volume

There is a distinct diversity between the appearance of every glioblastoma multiforme (GBM) on pretreatment magnetic resonance imaging (MRI) with a potential impact on clinical outcome and survival of the patients. The object of this study was to determine the impact of 10 different single nucleotide polymorphisms (SNPs) on various volumetric parameters in patients harboring a GBM. We prospectively analyzed 20 steroid-naïve adult patients who had been treated for newly diagnosed GBM. The volumetry was performed using MRI with the help of a semiautomated quantitative software measuring contrast enhancing tumor volume including necrosis, central necrosis alone and peritumoral edema (PTE). We calculated ratios between the tumor volume and edema (ETR), respectively necrosis (NTR). SNP analysis was done using genomic DNA extracted from peripheral blood genotyped via PCR and sequencing. There was a strong correlation between tumor volume and PTE (p0.001), necrosis (p0.001) and NTR (p = 0.003). Age and sex had no influence on volumetric data. The Aquaporin 4-31GA SNP had a significant influence on the ETR (p = 0.042) by decreasing the measured edema compared with the tumor volume. The Interleukin 8-251AT SNP was significantly correlated with an increased tumor (p = 0.048), PTE (p = 0.033) and necrosis volume (p = 0.028). We found two SNPs with a distinct impact on pretreatment tumor characteristics, presenting a potential explanation for the individual diversity of GBM appearance on MRI and influence on survival.

Eine bakterielle Spondylodiszitis kann zu schweren neurologischen Komplikationen fuhren oder in einen septischen Verlauf munden. Eine fruhzeitige Diagnosestellung und konsequente Therapie sind fur das Outcome der Patienten von entscheidender Bedeutung.

Background: Cerebrospinal fluid (CSF) leaks are well-known and frequent complications of intracranial procedures. Numerous studies have focused on the clinical aspects of incidence, risk factors, outcome, treatment, and prevention; however, large prospective multicenter studies are missing. The aim of this study was to prospectively analyze the rate of CSF leaks and their causes. Method: A total of 545 patients with a variety of intracranial procedures (elective and trauma) were recruited in a multicenter, prospective, observational study over a 12-month period. Results: In 545 cranial surgeries, we observed a CSF leak rate of 7.7% (n=42) at the time of discharge from the hospital. Significant risk factors for CSF leaks were posterior fossa surgery, opened pneumatized spaces, patients younger than 66 years, size of craniotomies, craniectomies rather than craniotomies, remaining dura defects larger than 1 cm, and wound closure without using muscle sutures, continuous locked, or unlocked sutures. Non-significant risk factors for CSF leaks were revision craniotomies, craniotomies for different pathologies, previous radiotherapy and/or systemic chemotherapy, augmentation of dura sutures with various materials, and wound drains as well as temporary CSF drains. Conclusion: Despite the number of techniques and developments for dural closure, the problem of CSF leaks remains evident and further improvement has to be made.

Chance discoveries of weapons, horse bones and human skeletal remains along the banks of the River Tollense led to a campaign of research which has identified them as the debris from a Bronze Age battle. The resources of war included horses, arrowheads and wooden clubs, and the dead had suffered blows indicating face-to-face combat. This surprisingly modern and decidedly vicious struggle took place over the swampy braided streams of the river in an area of settled, possibly coveted, territory. Washed along by the current, the bodies and weapons came to rest on a single alluvial surface.

Injuries relevant to neurosurgeons in central Europe are rarely caused by wild animal attacks, whereas dog bites in urban areas and farm-related attacks from cattle and horses are well-known to cause sometimes fatal head injuries. The authors describe the first case of a perforating frontobasal injury caused by a wild deer's antler. Associated lesions involved the endonasal area and the left orbit. A multidisciplinary approach was used to address all lesions in a one-stage operation resulting in a full recovery of the patient. Apart from the problem of a possible contamination of the head wound, injuries caused by wild animal attacks should be treated the same way as comparable "regular" cases. Adequate coverage of dural and bone defects with autologous material via a bifrontal intradural approach and meticulous debridement of the intracranial wound usually gives good functional and cosmetic results.

Image transfer by mobile phones with built-in cameras (1 Megapixel CCD digital camera, 7 stage digital zoom, max. picture size 858 x 1 144 pixels, display resolution 240 x 320 dots, 262 K colour system CGS LCD) was introduced into clinical practice in the author's department in July 2004 to improve communication between neurosurgeons. During the first 12 months of use 13-72 images per month with an average of 1.4 images/case were transmitted via the regular German mobile phone net (GRPS standard, 40 KBit/s) among all neurosurgeons. Most images were transferred from the resident on call to the senior neurosurgeon backing him up. Overall, the system was extremely reliable, quick, and enabled immediate decisions in all emergency situations. In conclusion, image transfer by mobile phones has significantly improved communication within our department.

Kopfschussverletzungen sind fur den Arzt im Rettungsdienst ein selteneres Ereignis. Die ausergewohnlichen Umstande von Verletzung und Rettungssituation konnen bei der Erstversorgung besonders den Unerfahrenen zu unbedachten Reaktionen und Handlungen veranlassen. Rationales und systematisches Vorgehen ist jedoch die Basis fur ein erfolgreiches Patientenmanagement. Pathophysiologisch lasst sich ein primarer, vorwiegend von der Geschossenergie bestimmter Hirnschaden vom sekundaren Hirnschaden abgrenzen. Nur letzterer ist mit seinen Hauptursachen Hypoxie, Hyperkapnie und Hypotonie behandelbar. Die Erstversorgung erfolgt nach den Richtlinien fur Schadel-Hirn-Traumen, einige Besonderheiten mussen aber beachtet werden. Bei isolierten Kopfschussverletzungen erfolgt die Einlieferung der Patienten nach Stabilisierung/Wiederherstellung der Vitalfunktionen in eine neurochirurgische Klinik. Fruhkomplikationen umfassen die Ausbildung intrakranieller Hamatome und die Entwicklung eines posttraumatischen Hirnodems. Intrakranielle Infektionen, posttraumatischer Hydrozephalus und posttraumatisches Anfallsleiden werden als Spatkomplikationen beobachtet. Patienten mit einem Glasgow-Koma-Score ≤6 Punkten haben eine extrem schlechte Prognose, wohingegen solche mit einem GCS >12 Punkten ihre Verletzung fast immer in einem guten Zustand uberleben.

According to European Brain Injury Consortium (EBIC) and American Brain Injury Consortium (ABIC) guidelines for severe head injuries, decompressive craniectomy is one therapeutic option for brain edema that does not respond to conventional therapeutic measures. As a result of the failure of all recently developed drugs to improve outcome in this patient group, decompressive craniectomy has experienced a revival during the last decade. Although class I studies of this subject are still lacking, there is strong evidence from prospective, uncontrolled trials that such an operation improves outcome in general and also has beneficial effects on various physiologic parameters that are known to be independent predictors for poor outcome. Whether this operation should be performed in a protocol-driven or in a prophylactic manner remains unclear. Decompressive craniectomy may, however, be the only method available in developing countries with limited ICU and monitoring resources. Prospectively controlled and randomized studies to definitively evaluate the effect of this old neurosurgical method on outcome in patients with traumatic brain injury (TBI) are forthcoming.

The Bronze Age site in the Tollense valley, Germany, has yielded thousands of human and animal bones and a number of archaeological artifacts. Several of the human bones exhibit blunt and sharp force lesions, and the assemblage has been interpreted as representing victims of a large scale conflict. One of the earliest finds is a human humerus with an embedded flint arrowhead. Alleged signs of healing initially reported for this humerus based on clinical CT imaging were interpreted as evidence of an antemortem lesion. The present study, using micro-CT imaging, revealed that the arrowhead lesion in the humerus, contrary to the previous interpretation, shows no signs of healing. The structure previously assumed to represent a sclerotic margin around the wound canal was shown to actually represent compacted trabecular debris. Thus, our re-analysis of the specimen led to a re-classification of the arrow wound as a perimortem lesion. The findings of the present study demonstrate the value of micro-CT imaging as a non-destructive method for obtaining information on the nature of bone lesions and healing reactions critical for the reconstruction of interpersonal conflict scenarios in the past.

Purpose To explore the additional health care costs of incidental durotomies and cerebrospinal fluid (CSF) leaks after elective surgery for degenerative spinal disorders. Methods Prospective, observational single-center study including all patients operated for a degenerative condition of the spine over a 13-month period. Incidental durotomies and cerebrospinal fluid leaks were registered prospectively and a detailed analysis of health care costs of each case was performed. Results In total 239 patients were included; an incidental durotomy occured in ten patients and a postoperative cerebrospinal fluid leak occured in one patient causing significantly higher hospital costs, as well as significantly longer hospital stay and operation time. While the hospital costs increased by nearly 50 % the hospitals reimbursement increased only by 21 % and this resulted in an average financial loss of 730 € per case. Conclusion Incidental durotomy or postoperative cerebrospinal fluid leak after elective surgery for degenerative spinal disorders causes significantly higher health care costs.

The neurosurgical treatment of space occupying processes in the central area bears a relatively high risk of either postoperative neurological deficits ("radical approach") or of residual tumor ("conservative approach"). Therefore, special techniques of intraoperative topographic orientation (image-guided surgery) play an important role here. The possible impact of neuronavigation on different neurosurgical steps (craniotomy, corticotomy, localization of the process, definition of borders of resection) was studied in relation to the site of pathology (extraaxial, intraaxial/superficial, intraaxial/deep) in 46 patients harbouring space occupying lesions of the central area. In intraaxial pathologies, additional electrophysiological monitoring was done. It could be shown, that in cases of deep seated processes, neuronavigation had the greatest impact on craniotomy, corticotomy and localization of the process, whereas the borders of resection were defined predominantly on the basis of differences in colour or consistency. In extraaxial pathologies, neuronavigation was of significance only for craniotomy; in intraaxial processes visible at the surface, it had an impact on craniotomy and--in a few cases--on definition of resection borders. In neurosurgery of intraaxial pathologies of the central area (particularly those not visible at the surface), the use of neuronavigation (or another method of intraoperative localization) in combination with neurophysiologic monitoring is strongly recommended.

The present study was conducted to evaluate the effects of nimodipine and mannitol on infarct size and on the amount of apoptosis after transient focal cerebral ischemia. Focal cerebral ischemia was induced in male Sprague-Dawley rats (weight 300-380 g) by transient occlusion of the right middle cerebral artery (MCAO) using an intraluminal thread model. All animals underwent ischemia for 2 h, followed by 24 h of reperfusion. Group I (n=16) was untreated. Group II (n=16) received 15% mannitol (1 g/kg as bolus) and group III (n=9) received 15 microg/kg/h nimodipine intravenously beginning 15 min prior to MCAO. Twenty-four hours after reperfusion, the brain was taken and sectioned in coronal slices. The slices were stained with HE and with the transferase dUTP nick-end labeling (TUNEL) technique. Histopathological analysis revealed a significant (P0.05) decrease in infarct size in the striatum with both drugs: mannitol (group II) 25.4+/-5.9% and nimodipine (group III) 21.5+/-11.0% versus control (group I) 34.9+/-7.0% and in the cortex 2.7+/-2.0% (group II) and 6.3+/-2.4% (group III) versus control 14.4+/-9.0% (group I). The number of apoptotic cells was statistically lower in the therapy groups (group III 9.6, group II 25.8) versus control (group I 57.9) (Mann-Whitney-Wilcoxon U-test Z1.96, P0.05). This study indicates that mannitol and nimodipine provide neuroprotection by preventing both the necrotic and apoptotic components of cell death after transient focal cerebral ischemia and may be effective as neuroprotective drugs for cerebrovascular surgery.

Object The author's personal series included 148 patients who sustained traumatic frontobasal injuries and were treated between 1986 and 1999. Included in this study are 74 of 148 patients with acute injuries and complex fronto-basal lesions involving the frontal sinus, the cribriform/ethmoid roof complex, one or both orbital roofs, and the planum sphenoidale. Methods Surgery was delayed for up to 4 weeks postinjury in most patients (67 cases), whereas 17 with space-occupying hematomas and perforating injuries required early surgery. In 30 patients additional surgery was required to treat maxillofacial fractures, which was performed as a one-stage procedure together with the neurosurgical operation. The author performed a standard bifrontal craniotomy in which an intradural or combined intradural–extradural approach was used in all cases. Four patients developed ascending meningitis in the preoperative period. As a result of surgical treatment one patient died, another two patients suffered from permanent defects, and three suffered from transitory neurological worsening. In two patients recurrence of a cerebrospinal fluid fistula occurred within a 3-month period posttreatment but was successfully obliterated during reoperation. In the author's experience the intradural approach is comparable in terms of the morbidity, mortality, and success rates with extracranial approaches; additionally the intradural approach provides full visualization of the intracranial lesion. Useful olfactory nerve function can only be preserved if both olfactory nerves are left intact and not crushed during initial injury; this occurred in only five patients in this series. Conclusions If possible, surgical treatment of more complex lesions should be delayed until the 2nd or 3rd week following traumatic injury. With antibiotic prophylaxis the risk that ascending meningitis will occur prior to surgery is low. If the patient is systemically stable and brain swelling has resolved, even extensive one-stage neurosurgical/ maxillofacial procedures are well tolerated.

✓ Control of bleeding during dissection is a problem that is still not completely resolved in neurosurgical procedures. To overcome this problem in some settings, the authors, in close collaboration with their institution, developed a new device for blunt dissection of brain tumors that is based on a waterjet technique. This report describes their first experimental and clinical experience with this new method. Numerous cutting experiments were performed in porcine cadaver brains. The best results were obtained using pressures from 4 to 6 bars with a 100-jxm tip, which produced very small, precise cuts. Histological evaluation showed no disruption or vacuolization of the surrounding tissue. The authors have used the new device in nine patients (seven with gliomas and two undergoing temporal lobe resections for epilepsy), and no complications have been observed. The waterjet device allowed dissection of the brain tissue while even small exposed vessels were spared injury. The instrument was found to be easy to use. Future investigations will concentrate on adapting this new method to endoscopic surgery and evaluating fluids with low surface tension to avoid foaming and bubbling during open surgery.

Cerebrospinal fluid (CSF) leaks are well-known and frequent complications of intracranial procedures with their clinical aspects covered by numerous studies. Little, however, is known about the pharmacoeconomical aspects of this specific complication. 545 patients with a variety of intracranial procedures (elective and trauma) were recruited for a multicenter, prospective, observational study over a 13-month period. A specific pharmacoeconomic analysis was performed in 168 of these patients from the institution of the first author covering all clinical and pharmaco-economical aspects of this specific complication. Of all patients, 5.36% developed a postoperative CSF leak. Treatment of the leak required numerous diagnostic and therapeutic procedures such as reoperations ( n = 6), lumbar punctures ( n = 11) or lumbar drainages ( n = 4). Costs for these procedures and prolonged hospital stays nearly doubled the costs per case (€14079/case without a fistula vs. €25499/case with a fistula). Reimbursement for the hospital covered these extra costs, but net earnings per case were diminished by €565 in cases with a CSF leak. The authors conclude that the presence of a CSF leak after an intracranial operation – although not influencing outcome in general – results in additional diagnostic and therapeutic procedures for the patient, an enormous increase in costs for the community, and a financial loss for the hospital. Strategies to lower this complication rate should therefore urgently be developed both from a clinical and a pharmacoeconomical point of view.

Wirkt eine Gewalt auf den Kopf ein, fuhrt sie, je nach Ausmas und Richtung der einwirkenden Kraft, zu Verletzungen von Kopfschwarte, Schadelskelett und Gehirn, die unter dem Begriff Schadel-Hirn-Trauma (SHT) zusammengefasst werden.

Trephinations in Neolithic people have been described all over the world. The reasons for these operations however are not always clear. In the present paper the authors describe the rare case of a Neolithic skull (dated to 1940 cal BC [calibrated before Christ]) showing the combination of a trephination combined with a healed depressed skull fracture. The authors conclude that at least in some cases such operations have been performed for "purely" medical reasons.