In 2005, a randomized trial showed that addition of surgery to radiotherapy improved outcomes in patients with metastatic spinal cord compression (MSCC). Since then, only a few studies compared ...radiotherapy plus surgery to radiotherapy alone. We performed a retrospective matched-pair study including data from prospective cohorts treated after 2005. Seventy-nine patients receiving radiotherapy alone were matched to 79 patients assigned to surgery plus radiotherapy (propensity score method) for age, gender, performance score, tumor type, affected vertebrae, other bone or visceral metastases, interval tumor diagnosis to MSCC, time developing motor deficits, and ambulatory status. Improvement of motor function by ≥1 Frankel grade occurred more often after surgery plus radiotherapy (39.2% vs. 21.5%,
= 0.015). No significant differences were found for post-treatment ambulatory rates (59.5% vs. 67.1%,
= 0.32), local progression-free survival (
= 0.47), overall survival (
= 0.51), and freedom from in-field recurrence of MSCC (90.1% vs. 76.2% at 12 months,
= 0.58). Ten patients (12.7%) died within 30 days following radiotherapy alone and 12 patients (15.2%) died within 30 days following surgery (
= 0.65); 36.7% of surgically treated patients did not complete radiotherapy as planned. Surgery led to significant early improvement of motor function and non-significantly better long-term control. Patients scheduled for surgery must be carefully selected considering potential benefits and risk of perioperative complications.
Purpose
The use of epinephrine (EN) or vasopressin (VP) in hemorrhagic shock is well established. Due to its specific neurovascular effects, VP might be superior in concern to brain tissue integrity. ...The aim of this study was to evaluate cerebral effects of either EN or VP resuscitation after hemorrhagic shock.
Methods
After shock induction fourteen pigs were randomly assigned to two treatment groups. After 60 min of shock, resuscitation with either EN or VP was performed. Hemodynamics, arterial blood gases as well as cerebral perfusion pressure (CPP) and brain tissue oxygenation (PtiO
2
) were recorded. Interstitial lactate, pyruvate, glycerol and glutamate were assessed by cerebral and subcutaneous microdialysis. Treatment-related effects were compared using one-way ANOVA with post hoc Bonferroni adjustment (
p
< 0.05) for repeated measures.
Results
Induction of hemorrhagic shock led to a significant (
p
< 0.05) decrease of mean arterial pressure (MAP), cardiac output (CO) and CPP. Administration of both VP and EN sufficiently restored MAP and CPP and maintained physiological PtiO
2
levels. Brain tissue metabolism was not altered significantly during shock and subsequent treatment with VP or EN. Concerning the excess of glycerol and glutamate, we found a significant EN-related release in the subcutaneous tissue, while brain tissue values remained stable during EN treatment. VP treatment resulted in a non-significant increase of cerebral glycerol and glutamate.
Conclusions
Both vasopressors were effective in restoring hemodynamics and CPP and in maintaining brain oxygenation. With regards to the cerebral metabolism, we cannot support beneficial effects of VP in this model of hemorrhagic shock.
Abstract This study is the first one to compare WBRT + SRS to OP + WBRT for 1–3 brain metastases. Survival (OS), intracerebral control (IC) and local control (LC) of the treated metastases were ...retrospectively evaluated in 52 patients undergoing WBRT + SRS and in 52 patients undergoing OP + WBRT. Both groups were matched for WBRT schedule, age, gender, performance status, tumour, number of brain metastases, extracerebral metastases, RPA class and interval from tumour diagnosis to WBRT. One-year OS was 56% after WBRT + SRS and 47% after OP + WBRT ( p = 0.034). One-year IC was 66% and 50% ( p = 0.003). One-year LC was 82% and 66% ( p = 0.006). On multivariate analyses, it was found that improved OS was associated with younger age ( p = 0.044), no extracerebral metastases ( p < 0.001), RPA class 1 ( p < 0.001) and longer interval from tumour diagnosis to WBRT ( p = 0.001). IC was associated with younger age ( p = 0.002) and longer interval ( p = 0.004); WBRT + SRS achieved borderline significance ( p = 0.052). Improved LC was associated with longer interval ( p = 0.017); WBRT + SRS showed a trend ( p = 0.09). WBRT + SRS appears at least as effective as OP + WBRT.
Abstract OBJECTIVE Percutaneous Dilatational Tracheostomy (PDT) is a commonly performed method in neurocritical care, whose safety has been proven in numerous studies. Nevertheless, there are poor ...data regarding the application in patients with acute brain injury and poor respiratory function. The purpose of this study was to evaluate the incidence of hypoxemia and hypercapnia during PDT in those patients. METHODS In a retrospective analysis, we acquired data from 54 patients with an acute brain injury (ABI) and a reduced PaO2 /FiO2 ratio (PaO2 /FiO2<300mmHg). In all cases, blood gas analyses before, during and approximately 12 h after PDT were available. We reviewed the patients’ ventilator settings, the results of gas exchange as well as radiographic signs of acute respiratory distress syndrome (ARDS). Patients with ARDS were defined using the Berlin criteria. RESULTS We observed 2 cases (3.6%) of intraoperative hypoxemia (PaO2 <60mmHg) and 4 cases (7.4%) of intraoperative hypercapnia (PaCO2 >55 mmHg). Twenty patients fulfilled the Berlin criteria for ARDS. While mean PaO2 did not differ significantly between ARDS and non-ARDS patients, intraoperative hypoxemia only occurred in the ARDS group (2/20). Mean PaCO2 was similar in the ARDS and non-ARDS group and cases of hypercapnia were apparent in both groups. The mean PaO2 /FiO2 ratio of all patients improved from 229.1 mmHg before PDT to 255.3 mmHg. CONCLUSIONS Regarding the intraoperative gas exchange, indication of PDT in patients with ABI and ARDS should be considered carefully. However, PDT in ABI patients with reduced PaO2 /FiO2 ratio alone appears to be a safe procedure.
Ventriculoatrial (VA) shunts inserted for the treatment of hydrocephalus are known to be a risk factor for pulmonary hypertension. The aim of this study was to evaluate the incidence of pulmonary ...hypertension among adult patients with VA shunts.
All patients who had received a VA shunt at one of two institutions between 1985 and 2000 were invited for a cardiopulmonary evaluation. The investigation included a thorough history taking, clinical examination, echocardiography, and pulmonary function testing including diffusing capacity of the lung for carbon monoxide (DLCO). Pulmonary hypertension was defined as systolic pulmonary artery pressure>35 mm Hg at rest.
The study group consisted of 86 patients, of whom 38 (44%) could be examined. The patients' mean age was 47.1±18.4 years; the median interval between shunt insertion and cardiopulmonary evaluation was 15 years (range 5-20 years). Of the 38 patients, 20 (53%) had Doppler velocity profiles of tricuspid regurgitation that were adequate for the estimation of pulmonary artery systolic pressure. Doppler-defined pulmonary hypertension was observed in 3 patients (8%), 2 of whom underwent right heart catheterization. Chronic thromboembolic pulmonary hypertension was confirmed in both patients, and medical therapy, including anticoagulation, was started. The VA shunt was removed in both cases and replaced with a different type of device. Pulmonary function tests revealed a restrictive pattern in 15% and typical obstructive findings in 9% of patients. In 30% of patients the DLCO was less than 80% of predicted, and blood gas analysis showed hypoxemia in 6% of patients. No significant differences in pulmonary function tests were noted between the patients with and without echocardiographic evidence of pulmonary hypertension. However, patients with pulmonary hypertension had significantly lower DLCO values.
The authors detected pulmonary hypertension by using Doppler echocardiography in a significant proportion of patients with VA shunts. It is therefore recommended that practitioners perform regular echocardiography and pulmonary function tests, including single-breath DLCO in these patients to screen for pulmonary hypertension to prevent hazardous late cardiopulmonary complications.
Many patients with brain metastases receive whole-brain radiotherapy (WBRT), despite the increasing use of stereotactic radiotherapy alone. A more recent approach includes WBRT combined with ...simultaneous integrated boost (WBRT+SIB). This study compared WBRT alone and WBRT+SIB for unresected brain metastases.
One-hundred-and-three patients receiving WBRT+SIB were compared to 275 patients receiving WBRT alone for intracerebral control (IC) and overall survival (OS).
Both treatment groups (WBRT alone and WBRT+SIB) were balanced with respect to patient characteristics. On multivariate analyses, WBRT+SIB (p=0.041), Karnofsky performance score (KPS) >70 (p<0.001), and 1-3 brain metastases (p=0.016) were significantly associated with IC. KPS >70 (p<0.001), favorable tumor type (p=0.011), 1-3 brain metastases (p=0.011), and absence of extracranial metastases (p<0.001) were significantly associated with OS.
WBRT+SIB is associated with improved IC but similar OS when directly compared to WBRT for brain metastases. Selected patients with a high risk of intracerebral recurrence may benefit from SIB.
Meningeal melanocytomas are rare tumors of the central nervous system and optimal treatment needs further clarification. This study compared subtotal resection (STR), STR plus radiation therapy (RT), ...gross total resection (GTR), and GTR+RT to better define the role of postoperative RT.
All cases reported in the literature were reviewed. Patients (n=184) with complete data were analyzed for local control (LC) and overall survival (OS).
On univariate analysis, GTR (vs. STR) was associated with improved LC (p=0.016). When comparing the treatment regimens, best and worst results were found after GTR+RT and STR alone, respectively (p<0.001). On univariate analysis, GTR resulted in better OS than STR (p=0.041). Moreover, the treatment regimen had a significant impact on OS (p=0.049). On multivariate analyses of LC and OS, extent of resection and treatment regimen were found to be significant factors. After STR, RT significantly improved LC but not OS. After GTR, RT did not significantly improve LC or OS.
GTR was significantly superior to STR regarding LC and OS. STR+RT resulted in significantly better LC when compared to STR alone.
To analyze angiographic characteristics of cerebral vasospasm (CVS) after spontaneous subarachnoid hemorrhage (sSAH) and their potential impact on secondary infarction and functional outcome.
...Demographic, clinical, and imaging data of sSAH patients with angiographic CVS admitted over a 6-year period were retrospectively analyzed.
A total of 85 patients were included in the final analysis. A total of 311 arterial territories in 85 angiographies demonstrated angiographic CVS. The anterior cerebral artery (ACA) was the most common site of angiographic CVS (42.1%), followed by the middle cerebral artery (MCA) (26.7%). In 29 angiographies (34%) CVS was found in more than 3 vessels and a bilateral pattern was identified in 53 cases (62%). Older age (OR 3.24 95% CI 1.30–8.07, P = 0.012) was identified as the only significant risk factor for CVS-related infarction (OR 22.67, P = 0.015). Unfavorable outcome was associated with older age (OR 3.24, P = 0.023) and poor World Federation of Neurosurgical Societies grade (OR 3.64, P = 0.015). Analyses of angiographic characteristics did not reveal any risk factors for unfavorable outcome. We identified distal CVS as a significant risk factor for CVS-related infarction (OR 2.89, P = 0.026).
Angiographic CVS after sSAH shows a specific distribution pattern in favor of ACA and MCA and in most cases 2–3 affected vessels are affected, often bilaterally. Patients exhibiting distal CVS have a higher risk for CVS-related infarction and should be observed closely. Nonetheless, the majority of angiographic characteristics did not allow conclusions about functional outcome nor the occurrence of CVS-related infarction in sSAH patients.
Endovascular interventions in patients with subarachnoid hemorrhage (SAH) and symptomatic cerebral vasospasm (sCVS) are commonly performed, but the potential benefits of repeated interventions have ...not been proven. The aim of this study was to show the potential burden and opportunities of repeated endovascular interventions in cases of recurrent sCVS.
We reviewed 15 patients with SAH who underwent more than 2 endovascular treatments of recurrent sCVS (CVS group) regarding the radiation doses, their clinical course, and their functional outcome. A case-control group of SAH patients without sCVS individually matched for age, World Federation of Neurosurgical Societies score, Fisher grade, and treatment modality was used as control group (non-CVS group).
A total of 70 endovascular treatments were performed in the CVS group. CVS group patients received longer mechanical ventilation (585 days vs. 439 days) and showed a higher rate of tracheostomy (12/15 vs. 7/15) and shunt-dependent hydrocephalus (6/15 vs. 2/15) than did the non-CVS patients. Moreover, patients from the CVS group underwent significantly (P < 0.001) more angiographies (median, 5 vs. 2) and CTP/CTA scans (median, 4 vs. 1) and consequently received significantly (P < 0.001) higher radiation doses. The rate of unfavorable outcomes (mRS 3–6) after 3 months was nonsignificantly higher in the CVS group (6/15 vs. 2/15), but after 6 months at least 5/14 patients from the CVS group showed a favorable outcome.
Repeated endovascular treatments of SAH patients with recurrent CVS are complex and expose the patients to high radiation doses. Nevertheless, favorable results could be achieved in patients in otherwise poor condition.
1.Endovascular treatment of sCVS is effective in patients with SAH.2.Repeated endovascular treatment strategies are very complex and expose the patients to high radiation doses.3.The consistent apply of endovascular treatments in these patients probably improve the outcome.
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