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Gamma knife radiosurgery for the treatment of glomus jugulare tumors

Journal of Neuro-Oncology. doi:10.1007/s11060-009-0002-6

The treatment of glomus jugulare tumors represents a challenge for the neurosurgeon, since they invade major vessels and compress critical cranial nerves, resulting in significant morbidity from tumor resection. Among alternative and complementary treatment options, gamma knife radiosurgery is a less invasive procedure and may provide better protection of vital structures. This study aimed to evaluate the efficacy and long-term outcomes of gamma knife surgery in the treatment of these tumors in a large series with the longest follow-up period compared with previous reports. A total of 18 patients with glomus jugulare tumors that underwent gamma knife radiosurgery (GKS) were included. Eleven patients had a history of previous microsurgical treatment. The mean marginal radiation dose was 15.6 Gy (median 15 Gy, range 13–20 Gy). Patients were followed for a mean period of 52.7 months (median 41.5 months); the effect of gamma knife radiosurgery was evaluated using magnetic resonance (MR) images. Based on the last MR images, tumor control could be achieved in 17 out of 18 patients (94.4%). No complications such as radiation-induced peritumoral edema or radiation necrosis occurred. Neurological follow-up examinations revealed improved clinical status in ten patients (55.6%), stable neurological status in seven (38.9%), and deterioration in one patient (5.5%). At the last visit, 17 out of 18 patients were alive. Our results indicate that stereotactic radiosurgery is an effective and safe treatment modality in the management of glomus jugulare tumors, particularly for residual or previously untreated small tumors.

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Glioma vascularity correlates with reduced patient survival and increased malignancy

Surgical Neurology Volume 72, Issue 3, September 2009, Pages 242-246. doi:10.1016/j.surneu.2008.11.012

The objective of this study was 2-fold: (1) document the presence and degree of vascularity in gliomas of different pathologic grades and (2) determine whether the presence of abnormal vascularity, determined by catheter angiography, correlates with a shortened survival.

Methods As part of a protocol for radiographic data acquisition that was used in a computer-assisted, stereotactic system, all patients who underwent biopsy or resection of a newly diagnosed glioma between 1994 and 2000 at our institution routinely underwent preoperative catheter angiography. The presence and degree of tumor vascularity were recorded and then correlated with survival and pathologic grade. The confounding effects of age, KPS, adjuvant treatment, and extent of resection on survival were considered.

Results Two hundred thirty-one patients were included in this study. The mean follow-up of survivors was 7.8 years. Tumor vascularity correlated with a shortened survival (proportional hazards RR for survival, 0.69; 95% CI, 0.58-0.82). This correlation persisted after correction for age, KPS score, adjuvant therapy, and extent of resection (RR, 0.81; 95% CI, 0.68-0.97). Abnormal vascularity was present in 25 (30%) of 82 low-grade (WHO grade 2) gliomas. Overall, the extent of vascularity (none [120 patients, 52%], blush [63 patients, 27%], neovessels [25 patients, 11%], and arteriovenous shunting [23 patients, 10%]) correlated with worse WHO tumor grade (P < .0001).

Conclusions The presence of abnormal vascularity correlates with both a shortened survival and higher grade of malignancy. These findings underscore the importance of antiangiogenesis factor investigation and drug development for the treatment of gliomas, regardless of their pathologic grade.

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Cell phones and brain tumors: a review including the long-term epidemiologic data

Vini G. Khurana, PhD, FRACS, Charles Teo, MBBS, FRACS, Michael Kundi, PhD, Lennart Hardell, MD, PhD, Michael Carlberg, MSc.

Surgical Neurology Volume 72, Issue 3, Pages 205-214 (September 2009) doi:10.1016/j.surneu.2009.01.019

The debate regarding the health effects of low-intensity electromagnetic radiation from sources such as power lines, base stations, and cell phones has recently been reignited. In the present review, the authors attempt to address the following question: is there epidemiologic evidence for an association between long-term cell phone usage and the risk of developing a brain tumor? Included with this meta-analysis of the long-term epidemiologic data are a brief overview of cell phone technology and discussion of laboratory data, biological mechanisms, and brain tumor incidence.

In order to be included in the present meta-analysis, studies were required to have met all of the following criteria: (i) publication in a peer-reviewed journal; (ii) inclusion of participants using cell phones for ≥10 years (ie, minimum 10-year “latency”); and (iii) incorporation of a “laterality” analysis of long-term users (ie, analysis of the side of the brain tumor relative to the side of the head preferred for cell phone usage). This is a meta-analysis incorporating all 11 long-term epidemiologic studies in this field.

The results indicate that using a cell phone for ≥10 years approximately doubles the risk of being diagnosed with a brain tumor on the same (“ipsilateral”) side of the head as that preferred for cell phone use. The data achieve statistical significance for glioma and acoustic neuroma but not for meningioma.

Conclusion

The authors conclude that there is adequate epidemiologic evidence to suggest a link between prolonged cell phone usage and the development of an ipsilateral brain tumor.

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Fronto-basal interhemispheric approach for tuberculum sellae meningiomas; long-term visual outcome

Ganna, Ahmed, Dehdashti, Amir R., Karabatsou, Konstantina and Gentili, Fred. British Journal of Neurosurgery,23:4,422-430, (2009).

URL: http://dx.doi.org/10.1080/02688690902968836

We report our experience with the treatment of tuberculum sellae meningiomas using the fronto-basal interhemispheric approach. A retrospective analysis was performed on a series of 24 patients with tuberculum sellae meningiomas who were operated between March 2000 and January 2007. Patients’ presenting symptoms, radiological images, operative reports, and clinical follow-up data were reviewed with special consideration for visual outcome. Visual deterioration was the presenting symptom in all patients, followed by headache in 9 patients (37.5%). The average duration of visual symptoms was 17.6 months. The average tumor diameter was 2.63 cm; encasement of the carotid artery was identified in 7 patients (29%). Complete tumor removal was achieved in 21 patients (87.5%). Mean follow-up period was 52 months. Vision improved in 19 patients (79%), remained stable in 4 (17%) and deteriorated in 1 patient (4%). The degree of tumor removal or visual outcome were both unrelated to the tumor size (p=0.2 and p=0.6 respectively). While the degree of preoperative visual deficit did not affect the visual improvement rate in the whole group (p=0.9), those patients with improvement to good functional vision (>20/40) after the surgery, had a less severe preoperative deficit (p<0.001). The most common complication was anosmia (29.1%) and there was no mortality. The frontobasal interhemispheric approach is safe and provides a direct anatomical approach to tuberculum sellae meningiomas with relatively low incidence of complications. Patients with improved vision to good functional level had a better preoperative visual status.

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A comparison between surgical resection in combination with WBRT or hypofractionated stereotactic irradiation in the treatment of solitary brain metastases

Peter Lindvall & Per Bergström & Per-Olov Löfroth &A. Tommy Bergenheim

Acta Neurochir (2009) 151:1053-1059

The standard treatment of solitary brain metastases previously has been tumour resection in combination with whole-brain radiation therapy (WBRT). Stereotactic radiotherapy has emerged as a non-invasive treatment option especially for small brain metastases. We now report our results on resection + WBRT or hypofractionated stereotactic irradiation (HCSRT) in the treatment of solitary brain metastases.

Between 1993 and 2004 patients with metastatic cancer and solitary brain metastases were selected for surgical resection + WBRT or HCSRT alone at the Umeå University Hospital. Fifty-nine patients were treated with surgical resection + WBRT (34 male, 25 female, mean age 63.3 years). Forty-seven patients were treated with HCSRT alone (15 male, 32 female, mean age 64.9 years). Findings In patients followed radiologically, 28% treated with resection + WBRT showed a local recurrence after a median time of 8.0 months, whereas there was a lack of local control in 16% in the HCSRT group after a median time of 3.0 months. There was a significantly longer survival time for patients treated with resection + WBRT (median 7.9, mean 12.9 months) compared to HCSRT (median 5.0, mean 7.6 months). Even in patients with a tumour volume <10 cc, there was a significantly longer survival in favour of resection + WBRT (median 8.4, mean 17.4 months) compared to HCSRT (median 5.0, mean 7.9 months).

Conclusion This retrospective and non-randomised study indicates that surgical resection in combination with WBRT may be an option even for small brain metastases suitable for treatment with HCSRT. Since survival and local control following resection + WBRT was at least as favourable as compared to HCSRT alone, tumour location and expected neurological outcome may be the strongest aspect when selecting treatment modality.

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Lessons learned by personal failures in aneurysm surgery: what went wrong, and why?

Knut Wester

Acta Neurochir (2009) 151:1013–1024


Purpose To analyse the intraoperative complications of a single neurosurgeon, with emphasis on devastating intraoperative incidents, and how they possibly could have been avoided.
Methods All the patients operated upon by the author between 1986 and 2002, i.e. 252 patients with 270 craniotomies for 294 aneurysms, were included. All intraoperative events that possibly could have influenced the clinical outcome were recorded prospectively.
Results A total of 16 cases (6.3% of all the patients) with serious intraoperative incidents were identified. In 11 cases (3.6% of all aneurysms), an intraoperative rupture occurred that was judged to have had mild to severe consequences for the patient. In another four patients (1.6% of all patients), all with unruptured, large aneurysms (>15 mm) of the carotid or middle cerebral arteries, a major vessel occlusion occurred inadvertently. In one patient with a large, unruptured MCA aneurysm, a clip slipped after the closure of the wound, causing a fatal intracerebral haemorrhage. These events had a severe impact on the clinical outcome. In retrospect, most of these incidents could, and should have, been avoided.

Conclusions It is recommended to start the training of new aneurysm surgeons on patients with small, supratentorial, unruptured aneurysms, followed by ruptured aneurysms in all other supratentorial locations than the anterior communicating artery (ACOM), which is the supratentorial location that should be the last step in the training of independent aneurysm surgeons.

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Functional outcome after language mapping for insular WHO Grade II gliomas in the dominant hemisphere: experience with 24 patients

Neurosurg Focus 27 (2):E7, 2009
Despite the report of recent experiences of insular surgery in the past decade, there has been no series specifically dedicated to studying functional outcome following resection of insular WHO Grade II gliomas involving the dominant hemisphere, in patients with no or only mild preoperative language deficit. In this article, the authors analyze the contribution of awake mapping for preservation of brain function, especially language, in a homogeneous series of 24 patients who underwent surgery for insular Grade II gliomas within the dominant insular lobe.

Methods
Twenty-four patients underwent surgery for an insular Grade II glioma involving the dominant hemisphere (22 left, 2 right), revealed by seizures in all but 1 case. The preoperative neurological examination result was normal in 17 patients (71%), whereas 7 patients presented with language disorders detected using an accurate language assessment performed by a speech therapist. All surgeries were performed on awake patients utilizing intra-operative language mapping involving cortical and subcortical stimulation.

Results
There were no intrasurgical complications or postsurgical sensorimotor deficits. Despite an immediate postoperative language worsening in 12 cases (50%), all patients recovered to a normal status within 3 months, and 6 cases even improved in comparison with their preoperative examination results. The 24 patients returned to normal social and professional lives. Moreover, the surgery had a favorable impact on epilepsy in all but 4 cases (83%). On control MR imaging, 62.5% of resections were total or subtotal. Three patients underwent a second or third awake surgery, with no additional deficit. All but 2 patients (92%) are alive after a mean follow-up of 3 years (range 3–133 months).

Conclusions
Although insular surgery was long believed to be too risky, the present results show that the rate of permanent deficit, especially dysphasia, following resection of Grade II gliomas involving the dominant insula has been dramatically reduced (none in this patient series), thanks to the systematic use of intraoperative awake mapping, even in cases of repeated operations. Furthermore, patient quality of life may be improved due to a decrease of epilepsy after surgery. Thus, the authors suggest systematically considering resection when an insular Grade II glioma is diagnosed after seizures in a patient with no or mild deficit, even a glioma invading the dominant hemisphere.

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Neurosurgical management of intracranial epidermoid tumors in children

J Neurosurg Pediatrics 4:91-96, 2009

Epidermoid tumors are benign lesions representing 1% of all intracranial tumors. There have been few pediatric series of intracranial epidermoid tumors reported previously. The authors present their experience in the management of these lesions.

The neurosurgical database at the Hospital for Sick Children was searched for children with surgically managed intracranial epidermoid tumors. The patients’ charts were reviewed for demographic data, details of clinical presentation, surgical therapy, and follow-up. Ethics board approval was obtained for this study.

Seven children, all girls, were identified who met the inclusion criteria between 1980 and 2007. The average age at surgery was 11.2 years (range 8–15 years), and the mean maximal tumor diameter was 2.1 cm. Headache was the most common presenting symptom, and 1 tumor was found incidentally. Most patients had normal neurological examinations, but meningism was found in 2 cases. There were 3 cerebellopontine angle lesions, 1 pontomedullary lesion, and 3 supratentorial tumors. Hydrocephalus developed in 1 patient after aseptic meningitis, and she underwent shunt placement. There were no operative deaths. Complete resection could be performed in 2 patients. One patient experienced a small recurrence that did not require a repeated operation, while 1 subtotally resected lesion recurred and the patient underwent a second operation.

Conclusions: Intracranial epidermoid tumors are rare in the pediatric population. Total resection is desirable to minimize the risk of postoperative aseptic meningitis, hydrocephalus, and tumor recurrence. Aggressive neurosurgical resection may be associated with cranial nerve or ischemic deficits, however. In these cases, neurosurgical judgment at the time of surgery is warranted to ensure maximum resection while minimizing postoperative neurological deficits.

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Long-Term Outcome of Patients With Multiple Cerebral Cavernous Malformations

Neurosurgery: September 2009 – Volume 65 – Issue 3 – p 450-455

Multiple cerebral cavernous malformations (MCCMs) typically occur in patients with a family history of these lesions. Literature on MCCMs is scarce, and little is known about their natural history.

Of 264 consecutive patients with cerebral cavernomas treated at the Department of Neurosurgery, Helsinki University Central Hospital, in the past 27 years, 33 patients had MCCMs. Lesions were categorized according to the Zabramski classification scale. Follow-up questionnaires were sent to all patients. Outcome was assessed using the Glasgow Outcome Scale, and amelioration of epilepsy was assessed using the Engel scale. All clinical data were analyzed retrospectively.

The mean age of patients at diagnosis was 44 years. Sex presentation was almost equal. Nine percent of all patients had a family history of the disease. Patients presented with epilepsy, acute headache, and focal neurological deficits. MCCMs were incidental findings in 2 patients. Altogether, 416 cavernomas were found: 70% supratentorial and 30% infratentorial. Fifteen patients had symptomatic hemorrhage before admission to our department. Surgery was performed on 18 patients. In most cases, the largest cavernoma was removed. Postoperatively, 1 patient experienced temporary hemiparesis, and another developed permanent motor dysphasia. No mortalities occurred. The mean follow-up time was 7.7 years. Twenty-six patients (79%) were in good condition. Among patients with epilepsy who underwent lesionectomy, 70% had an Engel class I outcome. On follow-up magnetic resonance imaging, 52 de novo cavernomas were found.

Surgical treatment of patients with MCCMs is safe. An extirpation of the clinically active cavernoma prevents further bleedings and improves outcome of epilepsy.

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Management of disc herniations with bi-radicular symptoms via combined lateral and interlaminar approach

Neurosurg Review

Large lumbosacral disc herniations causing bi-radicular symptoms are very rare clinical entities and may present a surgical challenge. This study was undertaken to evaluate the effectiveness of the simply modified combined lateral and interlaminar approach for the treatment of these unique disc herniations. Between 2000 and 2005, 18 patients with bi-radicular symptoms secondary to large disc herniations of the lumbar spine underwent surgery. There were 13 men and five women, ranging in age between 25 and 64 years (mean 54.3 years). In this three-step operation, the osseous areas that are not essential for the facet joint were removed and both upper and lower nerve roots were decompressed. There were no intraoperative or postoperative complications, except transient dysesthesia in one (5.5%) patient. The mean follow-up period was 62.6 months (range 36–96 months). At the latest follow-up examination, outcomes using the Macnab classification were excellent in 13 patients (72.2 %), good in four (22.2%) and fair in one (5.5%). Recurrent disc herniations and/or instability, either symptomatic or radiographic, have not occurred as a result of the procedure during the follow-up period. The combined approach described here is a safe and effective procedure in the surgical treatment of this subtype of disc herniations with bi-radicular involvement. It permits optimum decompression of both nerve roots, avoiding the risk of secondary spinal instability.

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Risk of Retreatment for Aneurysm Recurrence or Residual After Initial Treatment By Endovascular Coiling

Neurosurgery: August 2009 – Volume 65 – Issue 2 – p 311-315

Endovascular treatment of intracranial aneurysms is less invasive than surgical repair but poses a higher risk for aneurysm recurrence, which may necessitate retreatment, thus adding to the long-term risk. Cerebrovascular neurosurgeons from 8 institutions in the United States and Puerto Rico collaborated to assess the risk of retreatment for residual or recurrent aneurysms after the initial endovascular coiling.

Data were prospectively recorded for 311 patients with coiled intracranial aneurysms who underwent 352 retreatment procedures after angiographic or clinical recurrence (hemorrhage after initial coiling). Results analyzed included procedural complications and procedure-related morbidity. Morbidity was classified as major (modified Rankin scale score > 3) or minor, and temporary (<30 days) or permanent (>30 days).

Retreatment mortality was 0.85% per procedure and 0.96% per patient. Treatment-related rates were 0.32% per patient (0.28% per procedure) for permanent or temporary major disability; 1.29% for permanent minor disability (1.14% per procedure); and 1.61% for temporary minor disability (1.42% per procedure). Total risk for death or permanent major disability was 1.28% per patient and 1.13% per procedure.

Retreatment poses a low risk for patients with recurrences of intracranial aneurysms after initial coiling; this risk is smaller than that posed by the initial endovascular therapy. The risk of disability associated with retreatment for aneurysm recurrence after coiling must be considered prospectively in the choice of treatment but with the recognition that its effects are low in the overall management risk.

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Endovascular treatment of brain arteriovenous malformations using onyx: Results of a prospective, multicenter study

Journal of Neuroradiology (36) 3: 147 – 152 (01/06/2009)

Background and purpose. – To evaluate the safety and efficacy of onyx for embolization of brain arteriovenous malformations (BAVM). Methods. – A prospective, multicenter study was conducted in France to evaluate embolization of BAVM with onyx. From May 2003 to March 2005, 50 patients (26 females, 24 mates; mean age: 34.8 years, range: 16-64 years) were included. Clinical. Presentation was haemorrhage in 22 patients (44.0%), seizures in 16 patients (32.0%), headaches in six patients (12.0%) and progressive neurological. Deficit in two cases (4.0%). Four patients were asymptomatic (8.0%). Results. – One hundred and forty-nine sessions of embolization were performed: one to eight sessions/patient with a mean of 3.0 sessions. One hundred and sixteen sessions (77.9%) were performed with onyx, 20 sessions (13.4%) with glue and 13 sessions (8.7%) with onyx and glue. Symptomatic acute postembolization haemorrhage (APEH) was observed in four cases (8.0% per patient). At 1 month, morbidity and mortality related to the treatment were of 8% and 2%, respectively. Complete BAVM occlusion was obtained in 8.3% of cases. In the remaining cases, occlusion rate was between 99 and 80% in 56.3% of patients, 79 and 60% in 16.7%, and less than 60 in 18.7%. In case of incomplete occlusion, complementary treatment was performed by radiosurgery. Conclusion. – Onyx is suitable for BAVM embolization with acceptable morbidity and mortality.

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Infratentorial ependymomas: prognostic factors and outcome analysis in a multi-center retrospective series of 106 adult patients

Acta Neurochirurgica (151)8: 947 – 960. 01/08/2009

This study was undertaken to analyze outcomes and to assess the prognostic impact of age, location, surgery, radiotherapy (RT), and histopathology in a series of adult infratentorial ependymomas. This was a retrospective study of a population of 106 adult patients with infratentorial ependymomas diagnosed between 1990 and 2004. A central pathological review of all cases was performed. Grading was according to the WHO and Marseille’s neograding classifications. The series consisted of 58 males (54.7%) and 48 females (45.3%) in the age range of 18-82 years. Using the WHO classification, 88 patients (83.0%) had grade II and 18 patients (17.0%) grade III ependymomas. Using the Marseille’s neograding system, 91 patients were low-grade and 15 high-grade. Gross total resection was achieved in 66 patients (62.3%). Thirty-seven patients (35.0%) received adjuvant RT. The 5- and 10-year overall survival rates for the entire cohort were 86.1% and 80.5%, respectively. On multivariate analysis, a preoperative Karnofski performance status score > 80, no recessus lateral extension and a low histological grade (Marseille’s grading) were associated with a longer overall survival. The 5- and 10-year progression-free survival rates for the entire cohort were 70.8% and 57.7%, respectively. On multivariate analysis, no recessus lateral extension, gross total resection and a low histological grade (Marseille’s grading) were associated with a longer progression-free survival. Adjuvant RT was significantly associated with a better overall and progression-free survival in incompletely resected WHO grade II ependymomas. This study highlights the key role of histology in the clinical outcome and the fact that gross total resection is a main prognostic factor and the treatment of choice for posterior fossa ependymomas. The use of adjuvant RT in patients with incompletely resected WHO grade II ependymomas appears beneficial, but its effect on high-grade tumors remains to be determined.

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Implantation of Deep Brain Stimulator Electrodes Using Interventional MRI

Philip A. Starr, MD, Alastair J.Martin, PhD, Paul S. Larson, MD

Neurosurgery Clinics of North America

Volume 20, Issue 2, Pages 207-217 (April 2009)

The authors describe a method for placement of deep brain stimulator electrodes using interventional MRI in conjunction with a skull-mounted aiming device (Medtronic Nexframe). This approach adapts the procedure to a standard-configuration 1.5-T diagnostic MRI scanner in a radiology suite. Preoperative imaging, device implantation, and postimplantation MRI are integrated into a single procedure performed under general anesthesia, providing real-time, high-resolution magnetic resonance confirmation of electrode position. The method is conceptually simpler than the current standard technique for deep brain stimulator placement, as it eliminates the stereotactic frame, the subsequent requirement for registration of the brain in stereotactic space, physiologic testing, and the need for patient cooperation. With further technical refinement, the interventional MRI method should improve the accuracy, safety, and speed of deep brain stimulator electrode placement.

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A Randomized Trial of Vertebroplasty for Osteoporotic Spinal Fractures

NEJM (361): 569-579. Aug 6, 2009

Vertebroplasty is commonly used to treat painful, osteoporotic vertebral compression fractures.

Methods In this multicenter trial, we randomly assigned 131 patients who had one to three painful osteoporotic vertebral compression fractures to undergo either vertebroplasty or a simulated procedure without cement (control group). The primary outcomes were scores on the modified Roland–Morris Disability Questionnaire (RDQ) (on a scale of 0 to 23, with higher scores indicating greater disability) and patients’ ratings of average pain intensity during the preceding 24 hours at 1 month (on a scale of 0 to 10, with higher scores indicating more severe pain). Patients were allowed to cross over to the other study group after 1 month.

Results All patients underwent the assigned intervention (68 vertebroplasties and 63 simulated procedures). The baseline characteristics were similar in the two groups. At 1 month, there was no significant difference between the vertebroplasty group and the control group in either the RDQ score (difference, 0.7; 95% confidence interval [CI], –1.3 to 2.8; P=0.49) or the pain rating (difference, 0.7; 95% CI, –0.3 to 1.7; P=0.19). Both groups had immediate improvement in disability and pain scores after the intervention. Although the two groups did not differ significantly on any secondary outcome measure at 1 month, there was a trend toward a higher rate of clinically meaningful improvement in pain (a 30% decrease from baseline) in the vertebroplasty group (64% vs. 48%, P=0.06). At 3 months, there was a higher crossover rate in the control group than in the vertebroplasty group (43% vs. 12%, P<0.001). There was one serious adverse event in each group.

Conclusions Improvements in pain and pain-related disability associated with osteoporotic compression fractures in patients treated with vertebroplasty were similar to the improvements in a control group. (ClinicalTrials.gov number, NCT00068822 [ClinicalTrials.gov] .)
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Infections associated with indwelling ventriculostomy catheters in a teaching hospital

International Journal of Infectious Diseases – 03 August 2009 (10.1016/j.ijid.2009.04.006)

Ventriculostomy-associated infections are a serious complication of external ventricular drains. The objective of this study was to analyze the clinical features of and risk factors for such infections.

Methods

We retrospectively collected demographic and clinical data on patients with indwelling ventriculostomy catheters hospitalized in a teaching hospital from July 2001 to June 2006, comparing those with and without ventriculostomy-associated infections.

Results

A total of 197 drains (2910 catheter-days) placed in 155 patients were studied. Infections developed in 28 of the 197 (14.2%) drains. The duration from insertion to infection ranged from 7 to 36 days. The cut-off point of duration from insertion to infection was 15.5 days. Re-insertion because of catheter malfunction carried a high risk of infection (p<0.001). Patients with infections had a longer intensive care unit stay (p=0.001), longer duration of catheterization (p=0.002), and a higher incidence of concurrent sepsis (p=0.018), urinary tract infection (p=0.011) and pneumonia (p=0.004). Gram-negative bacilli were the leading pathogens (84%); Pseudomonas aeruginosa was the most common isolate. Polymicrobial infections occurred later than monomicrobial infections (p=0.003).

Conclusions

Repeated insertion and longer duration of drains are major risk factors for ventriculostomy-associated infections.

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EANS YOUNG NEUROSURGEONS MEETING 2010 21ST – 24TH FEBRUARY 2010

We are delighted to open registration for the EANS Young Neurosurgeons Meeting, to be held in February 2010.   This is intended as an event which will combine fierce scientific discussion and time to socialise in an informal atmosphere – please submit your application as soon as possible – the initial response to this event has been excellent, and we anticipate a good deal of interest.

However there is always a financial risk attached to the organisation of a new event, particularly in the current economic climate, and we need the firm financial commitment of a minimum number of participants by the end of the preliminary registration period (20th September 2009) if we are definitely to go ahead with the event.

This is intended as an event organised by Young Neurosurgeons for Young Neurosurgeons – so please, register now and play your part in making our event happen, keeping in mind that we have limited places available. We hope that many alumni from the EANS Training Courses will choose to attend, and are seeking to cultivate a similar atmosphere  – however we will also be delighted to welcome those who did not attend the courses, and those from outside Europe.

The morning sessions will consist of lectures from leading figures in European Neurosurgery and a series of “Challenging Topics” in which the merits of different approaches are considered, while the evening sessions will offer a valuable opportunity for recently qualified neurosurgical specialists to present their own work (abstracts to be submitted).

We hope that both sessions will give rise to animated discussions between both participants and faculty members – which can be continued during the afternoon on the ski slopes, when we anticipate that many people will choose to take advantage of the special ski deal which we have negotiated – though Innsbruck itself also has plenty to offer non skiers.

The event is focused particularly on those who have recently qualified, and the submission of abstracts is restricted to those within six years of specialist qualification.  However registration is open to those of all ages, and we hope that the event will provide the opportunity for discussion not only with your peers, but also with senior faculty members.

Please submit your registration form to Susie Hide susie.hide@btinternet.com as soon as possible.   Susie will then send you a link to our online payment facility.  As explained above, we need your firm financial commitment prior to September 20th, and will therefore require a minimum deposit of 300 Euros to be paid within this period.

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Surgical treatment of the extratemporal epilepsies

Epilepsia, Aug 12 2009

Epilepsy that originates outside of the temporal lobe can present some of the most challenging problems for surgical therapy. These epilepsies can be broadly categorized as lesional or non-lesional, with the nonlesional cases being the most difficult to localize. Lesional cases can result from malformations of cortical development, tumors, vascular malformations, or areas of old injury. Some lesions, such as focal cortical dysplasia, can be challenging, in that the boundaries of the pathology can be difficult to define. Presurgical goals include defining the structural lesion, the physiologic abnormality, and normal function in the area. These goals can be achieved using a variety of noninvasive and invasive tests. Surgical techniques vary depending on location and pathology but they always include removal of the epileptic brain tissue while preserving en passage vessels and underlying white matter tracts. Surgical outcomes vary depending on the underlying pathology. Surgeries are usually planned with a goal of no expected postoperative deficits, although temporary deficits may be anticipated in some areas, such as the supplementary motor cortex. Extratemporal epilepsy can be managed well with surgical treatment; but proper patient selection, evaluation, and discussion of expected outcomes and risks are critical in this challenging patient population.

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Use of the h index in neurosurgery

Journal of Neurosurgery, Aug 2009, Vol. 111, No. 2, Pages 387-392

Object
Assessing academic productivity through simple quantification may overlook key information, and the use of statistical enumeration of academic output is growing. The h index, which incorporates both the total number of publications and the citations of those publications, has been recently proposed as an objective measure of academic productivity. The authors used several tools to calculate the h index for academic neurosurgeons to provide a basis for evaluating publishing by physicians.

Methods
The h index of randomly selected academic neurosurgeons from a sample of one-third of the academic programs in the US was calculated using data from Google Scholar and from the Scopus database. The mean h index for each academic rank was determined. The h indices were also correlated with various other factors (such as time spent practicing neurosurgery, authorship position) to identify how these factors influenced the h index. The h indices were then compared with other citation statistics to evaluate the robustness of this metric. Finally, h indices were also calculated for a sampling of physicians in other medical specialties for comparison.

Results
As expected, the h index increased with academic rank and there was a statistically significant difference between each rank. A weighting based on position of authorship did not affect h indices. The h index was positively correlated with time since American Board of Neurological Surgery certification, and it was also correlated with other citation metrics. A comparison among medical specialties supports the assertion that h index values may not be comparable between fields, even closely related specialties.

Conclusions
The h index appears to be a robust statistic for comparing academic output of neurosurgeons. Within the field of academic neurosurgery, clear differences of h indices between academic ranks exist. On average, an increase of the h index by 5 appears to correspond to the next highest academic rank, with the exception of chairperson. The h index can be used as a tool, along with other evaluations, to evaluate an individual’s productivity in the academic advancement process within the field of neurosurgery but should not be used for comparisons across medical specialties.

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Risk factors for postoperative systemic complications in elderly patients with brain tumors

In elderly patients with brain tumors, the prevention of postoperative systemic complications is extremely important, and identification of the risk factors would be useful for planning therapy. The authors investigated ways to avoid postoperative complications by identifying risk factors.

Methods
The study population included 84 patients, 70 years of age or older, who underwent surgical brain tumor removal. The following independent factors were assessed by univariate and multivariate analyses: sex, age, preoperative underlying diseases and complications, histopathological findings, preoperative Karnofsky Performance Scale (KPS) score, preoperative whole blood hemoglobin (Hb) level, preoperative serum total protein (TP) level, operation time, intraoperative blood loss, change in Hb level (difference between pre- and postoperative values), and change in TP level (difference between pre- and postoperative values). The cutoff values for significant independent factors were also determined.

Results
Overall, 35 (41.7%) of the 84 patients had a total of 56 postoperative systemic complications. Univariate analysis identified the preoperative KPS score, intraoperative blood loss, change in Hb level, and change in TP level as risk factors for postoperative complications, and multivariate analysis extracted the following risk factors: the preoperative KPS score (p = 0.0450, OR 4.020), intraoperative blood loss (p = 0.0104, OR 6.571), and change in Hb levels (p = 0.0023, OR 9.301). The cutoff values were: KPS score < 80%, intraoperative blood loss ≥ 350 ml, and change in Hb level ≥ 2.0 g/dl.

Conclusions
In elderly patients with brain tumors, low preoperative KPS score, high intraoperative blood loss, and a large difference between pre- and postoperative Hb levels are significant risk factors for postoperative systemic complications.

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