Sektionstage Herbst 2023 der Deutschen Gesellschaft für Neurochirurgie

Dr. med.

PD Dr. med.

Prof. Dr. med.

Prof.

Clinical outcome and complications after endovascular vasospasmolysis in patients with aneurysmal subarachnoid hemorrhage

Subarachnoidalblutung / Aneurysmen

Intrazerebrale Blutungen

Abstract-Text Objective: While technical advancements improve aneurysm treatment, the patient's outcome after aneurysmatic subarachnoid hemorrhage (aSAH) hinges on delayed cerebral ischemia (DCI), mainly caused by vasospasm in large intracranial arteries (CVS)[1]. CVS, occurring in up to 70% of aSAH patients between days 4 and 14, is the leading cause of acute focal cerebral ischemia, resulting in death for about one-third and disability for another third of affected individuals[2, 3]. The present study aimed to investigate the benefit of endovascular therapy for large-artery vasospasms and DCI after aneurysmal aSAH. Methods: Data of patients with aSAH who were treated between March 2006 and March 2020 in our department was retrospectively analyzed regarding general medical and radiological data, aneurysm treatment strategies, and development of CVS. Delayed ischemic neurological deficit (DIND) was defined as occurrence of new neurological deficit and/or decline in at least 2 points on the Glasgow Coma Scale for no other reasons for patients who were able to be monitored by clinical examination. In patients who were unconscious or sedated due to the poor condition, clinically relevant CVS was defined by TCD mean velocities of &gt;200 cm/sec. The outcome was accessed immediately after eSL and at discharge by either clinical improvement in awake or occurrence of new cerebral infarcts in poor graded aSAH patients. Results: Overall, 853 Patients with acute aSAH were treated. Of those, 310 (36%) suffered from severe vasospasm. Conservative treatment including induced hypertension was performed in all patients. 92 patients (30%) underwent endovascular vasospasmolysis (eSL) due to persistent symptoms despite conservative therapy. Among endovascularly treated patients 79 patients (86%) improved in terms of angiographic results, 65% (n=33) improved clinically. Clinical worsening despite eSL occurred in 22% of cases (n=11). Periprocedural complications were observed in 4% (n=4). In 4 out of 12 unconscious or sedated patients (33%) no new cerebral infarcts were observed at discharge. Conclusion: Roughly a third of patients with CVS develop DIND despite conservative therapy. ESL appears to be a valuable and favorable therapeutic option for patients with persistent delayed ischemic deficits demonstrating promising clinical and radiological outcomes with low rates of periprocedural risks. Careful evaluation and continuous advancements in spasmolysis techniques are crucial in addressing cases of clinical deterioration after vasospasmolysis and further optimizing outcomes of patients. The advantages of eSL for patients with poor-graded patients remain uncertain.

Abstractvortrag

Microvascular perfusion in patients with aneurysmal subarachnoid hemorrhage

Klinische Studien

Freie Themen

Abstract-Text Background: Aneurysmal subarachnoid hemorrhage (aSAH) may lead to both micro- and macrovascular spasms, resulting in impaired cerebral perfusion and, ultimately, in delayed cerebral ischemia (DCI). While spasm of larger cerebral arteries can be detected by perfusion computed tomography (CTP) or digital subtraction angiography (DSA), perfusion changes of the cerebral microcirculation, which is suggested to be significantly affected after SAH, are not part of routine clinical assessments. Aim of study: Developing an algorithm to assess and quantify the perfusion of the cerebral microcirculation in datasets obtained from standard 2D-DSA. Methods: DSA datasets obtained from aSAH patients (n=8; WFNS: 5) and age-matched healthy controls (n=8) admitted to LMU Klinikum from January 1st, 2010, to February 15th, 2023 with a mean age of 54,3 years were analyzed. Time density curves of the contrast agent bolus in ROIs (regions-of-interest) located over the extra- and intracranial segments of the internal carotid artery, the sigmoid sinus in both anterior-posterior (A) and sagittal (B) plane; three ROIs over the M2 branches of the middle cerebral artery and six areas of the cerebral cortex with no visible larger vessels in the B plane vs. two ROIs over the middle cerebral artery as well as two regions-of-interest over the anterior cerebral artery and four peripheral cortex areas in the A plane were analyzed using a custom MATLAB algorithm to calculate peak density, TTP (time-to-peak), rTTP A &amp; rTTP B (relative TTP in A or B plane), AUC (area under the curve), FWHM (full width at half maximum), and MS (maximal slope). Results: Aneurysms were located at the ICA (n=2), the MCA (n=2), the ACoA (n=2), and in the posterior cerebral circulation (n=2). FWHM and MS were statistically different between the aSAH and the control group. Conclusion: The currently developed analysis allows to assess microcirculatory flow, i.e. tissue perfusion, using DSA datasets obtained during routine clinical workups. FWHM and MS seem to be promising angiographic markers to quantify cerebral microcirculatory flow following SAH and may thus help to detect microcirculatory dysfunction early after the onset of SAH. Further analyses are ongoing to validate these findings in a large, international multi-center cohort of SAH patients.

Influence of periinterventional anticoagulation on secundary hemorrhagic complications as well as correct placement of external ventricular drainage on puncture channel bleeding in patients with subarachnoidal hemorrhage

Hydrozephalus

Abstract-Text Objective: There is limited data regarding secondary hemorrhagic complications (SHCs) in patients with acute subarachnoid hemorrhage (SAH), mostly restricted to ventriculostomy-associated bleeding. There is even less data concerning intraparenchymal SHCs in patients with perinterventional anticoagulation as well as on correct placement of external ventricular drainage (EVD) and its influence on puncture channel bleeding (PCB). Aim of this study is to shed further light on the above raised questions. Methods: This prospective register study evaluated data of 87 patients which were treated from 09/2021 to 07/2023 in our department. 56 patients were treated with an EVD after admission before the necessary clipping or radiological intervention, the latter on 58 patients, was performed. Periinterventional anticoagulation (PIAC) was administered according to neuroradiological treatment decision in a total of 44 patients. SHCs were categorized as peripheral hemorrhage (PH), intracerebral hemorrhage (ICH) and central hemorrhage (CH). Moreover the correct placement of EVD and associated PCB was registered. Results: A total of 27 patients (31%) suffered SHCs, 7 (26%) of which were CH, 5 (19%) PH and 3 (11%) ICH. 11 patients (41%) had a combined CH and ICH, one patient (4%) showed signs of all three types of SHC. Of all patients with SHCs 15 (56%) were given PIAC (p=0,533). In 49 (88%) of the 56 patients that received an EVD the correct placement was confirmed, 5 patients (10%) developed PCB. Imaging showed incorrect placement (i.e. cross over) of EVD in 7 patients (13%) of which one patient (14%) suffered a PCB (p=0,569). Conclusion: SHCs are a known complication of SAH. This study showed no significant connection between the administration of PIAC and SHCs. The placement of the EVD seems to have no influence on PCB.

Incidence of delayed cerebral ischemia related to the way of application of Nimodipin in patients with acute subarachnoidal hemorrhage

Abstract-Text Objective: Acute subarachnoidal hemorrhage is characterized by a high mortality rate and morbidity. Improvement of neurological symptoms is rarely seen if severe deficits are caused by delayed cerebral ischemia or vasospasms, typically occurring three to fourteen days after the initial hemorrhage. Data regarding vasospasms and delayed cerebral ischemia (DCI) is controversial. The objective of this study is to find out whether the way of application of Nimodipin therapy (p.o. vs. i.v. vs. i.a.) affects the risk of developing DCI. Moreover the improvement of cognitive deficits over time will be evaluated. Methods: This prospective study describes 84 patients so far, ranging in age from 27 to 84. All patients were treated for acute subarachnoidal hemorrhage in our ward for neurosurgery from 09/2021 to 07/2023. Digital substraction angiography (DSA) is routinely performed in patients with acute subarachnoidal hemorrhage to screen for underlying aneurysms. The Montreal-Cognitive-Assessment-Test (MoCA) was used after the admission as well as three months later to evaluate cognitive outcome. Results: DSA showed initial vasospasm in twelve patients (14%) and caused cerebral ischemia in two patients (14%). A total of 49 patients (58%) developed vasospasm up to fourteen days after the initial hemorrhage. 61 patients (73%) needed i.v. Nimodipin therapy of which 13(21%) developed DCI. Another twelve (14%) received i.a. Nimodipin, four (33%) developed DCI. In 46 patients (55%) Nimodipin was administered p.o. with four (9%) of those developing DCI. One patient (1%) did not receive Nimodipin initially but needed subsequent i.v. therapy. Due to severe vasospasms the way of application had to be switched to i.a. in ten patients (12%), which led to four patients (40%) developing DCI. There is data regarding neurological outcome from 55 patients. 28 of those patients (51%) showed cognitive deficits at the time of admission ( 26 points in MoCA. Conclusion: More than half of the study population developed vasospasm following acute subarachnoidal hemorrhage, which required intensive treatment. Nimodipin was administered in all patients, resulting in comparable incidence of DCI for p.o. and i.v. application. In contrast 40% of patients receiving i.a. Nimodipin developed DCI. Whether this is due to the severity of vasospasm leading to the need for i.a. application or the treatment itself remains unclear. Cognitive function improved in over 36% of patients that had cognitive deficits at the time of admission. Cognitive deterioration in patients initially showing normal cognitive function was rarely seen.

Prof. Dr.

Prof. Dr med.

Elaborating reliable indicators for malignant transformation of ischemic stroke requiring decompressive hemicraniectomy – The malignant stroke indicator

Kraniektomie + Kranioplastie

Abstract-Text Objective: Decompressive craniectomy (DHC) has been demonstrated to effectively prevent mortality in patients with progressive brain edema associated with ischemic stroke (IS). Although several factors have been identified contributing to progressive edema no clear selection criteria have been established so far for a reliable and early identification of patients, who will develop malignant IS requiring DHC. The aim of this study was to assess the discrimination power of clinical and radiological parameters for indicating DHC after IS and to develop a scoring system indicating a high risk for malignant transformation. Methods: A large interdisciplinary database of patients treated with IS at our center between 2010 and 2021 was retrospectively reviewed. Parameters, known to be associated with malignant IS possibly requiring DHC, were included in the initial correlation analysis: age, previous stroke, basal cistern effacement, midline shift, intravenous lysis, successful recanalization (TICI at least 2b), ASPECTS on native CT as well as on CT perfusion, NIHSS and glucose level on admission. ROC – analysis was done to determine the cutoff values for each parameter, that was included in the development of the scoring system. Results: A total of 534 patients were included in the study, in 153 (29%) of whom DHC was performed. Based on the parameters that were significantly associated with the need for DHC, a scoring system (Malignant Stroke Indicator = MSI) was created for identification of patients, who will develop malignant stroke requiring DHC (table 1). The elaborated MSI-score ranging from 0 to 23 showed a strong correlation with the need for DHC (r=0.69, p&lt;0.0001). After performing ROC-analysis a cutoff value of MSI-score &gt; 7 was found to have the highest discrimination power between patients needing DHC and those who don"t (AUC 0.90, p&lt;0.0001). Patients with a MSI-score &gt; 7 had a 17-fold higher probability of requiring DHC compared to those with a MSI-score of 7 or less (OR 17.01, PPV 0.80, NPV 0.81, p&lt;0.0001). Conclusion: The MSI score is a reliable tool to predict the need for DHC at an early stage. The discrimination power is higher than that of comparable scores.

Analyse von Liquor-Drainagemengen und Hirndruckspitzen in Patient:innen nach Subarachnoidalblutungen – Eine Substudie des multicenter EARLYDRAIN trials

Abstract-Text Fragestellung: Die aneurysmatische Subarachnoidalblutung (aSAH) ist eine lebensbedrohliche Erkrankung, die mit erheblicher Morbidität und Mortalität assoziiert ist. Dabei ist insbesondere ein erhöhter intrakranialer Druck (ICP) aufgrund einer gestörter Liquor(CSF)-Dynamik ein kritischer Zustand, der typischerweise mittels Drainage von Liquor behandelt wird. Die optimalen Strategien bezüglich der Liquordrainagen sind jedoch weiterhin unklar. Die EARLYDRAIN-Studie zeigte, dass eine prophylaktische Lumbaldrainage nach Aneurysmabehandlung das neurologische Ergebnis verbessert. Die nun hier vorliegende Studie zielt darauf ab, den Einfluss von Liquordrainagen und ICP-Spitzen auf das Outcome von Patient:innen nach aSAH zu untersuchen. Methoden: Es handelt sich um eine Substudie des prospektiven, multizentrischen, randomisiert, kontrollierten EARLYDRAIN-trials. Als Outcome wurden die modifizierte Ranking-Skala (mRS) nach 6 Monaten und das Auftreten von sekundären Infarkten definiert. Wir analysierten die Liquormengen und die ICP-Werte der rekrutierten Patienten. Ein positives Ethikvotum liegt vor. Die Studie ist unter der ClinicalTrials.gov Nummer NCT01258257 registriert. Ergebnisse: Die CSF-Drainagemenge und der ICP von 287 Patient:innen wurden analysiert. Die durchschnittliche Liquor-Gesamtdrainagemenge innerhalb der ersten acht Tage nach Behandlung der SAH betrug 1052 ± 659 ml. Die gesamt CSF-Drainagemenge unterschied sich dabei nicht zwischen Patient:innen mit gutem und schlechtem neurologischem Outcome. Jedoch zeigten Patient:innen mit schlechtem neurologischen Outcome eine signifikant höhere Gesamtdrainagemenge über externe Ventrikel Drainagen (EVD) (p &lt; 0,01). Im Gegensatz dazu war eine höhere Liquor Drainage durch lumbales Systeme (LD) mit einem positiven Outcome assoziiert (p &lt; 0,03). Der mediane prozentuale Anteil an der Gesamtdrainagemenge von Liquor der über eine LD abgelassen wurde, unterschied sich signifikant zwischen gutem und schlechten Outcome (48 % (gut) vs. 25 % (schlecht), p &lt; 0,001) und dem Auftreten von sekundären Infarkten (46 % (ohne Infarkt) vs. 26 % (mit Infarkt), p = 0,001). Der Höchstwert des gemessenen ICP nach dem Blutungsereignis war bei Patienten mit ungünstigem neurologischem Ergebnis signifikant erhöht (p &lt; 0,001). Schlussfolgerungen: Ein hoher Liquordrainagemenge durch eine EVD ist mit einem schlechteren neurologischen Outcome und mehr sekundären Hirninfarkten nach aSAH verbunden. Patienten mit besserem Ergebnis zeigen höhere Mengen und Prozentsätze an CSF-Drainage durch ein lumbales System, was auf einen potenziellen mengenabhängigen Schutzeffekt durch Lumbaldrainage hinweist. Basierend auf den Ergebnissen der aktuellen Studie würden die Autoren vorsichtig vorschlagen, das durch LD drainierte Volumen zu maximieren und empfehlen, eine ICP-Messung routinemäßig durchzuführen, um ICP-Spitzen über 25 mmHg strikt zu verhindern.

PD Dr.

Prof. Dr. Dr.

PD Dr.med.habil.

Evaluation of predictive parameters for size progression of intracranial hemorrhage in patients with extracorporeal membrane oxygenation (ECMO)

Abstract-Text Objective The treatment of patients with severe underlying pulmonary or cardiac diseases and the performance of extracorporeal membrane oxygenation (ECMO) have gained in importance in recent years, not least because of the Covid pandemic. Despite of the technical innovations, ECMO treatment is still challenging. Intracranial hemorrhage is one of the feared complications, which limits patient"s outcome severely. In addition, it is necessary to accompany ongoing ECMO therapy with heparinization to avoid thrombosis. Some patients experience intracranial hemorrhage of varying degrees. To date, the pathomechanism for the severity grade of neurological complications in ECMO patients has not been clearly clarified. The aim of our study is to detect predictive factors that favor intracranial hemorrhage and to detect which aspects cause a devastating increase in initially small hemorrhages. Methods We performed a retrospective data analysis of 334 patients with ECMO implantation in the period 2020 to 2023. Patients with intracranial bleeding (intracerebral, subdural, intraventricular or subarachnoid) were identified. Admission status, patient´s characteristics, coagulation parameters, extent of bleeding (volume) and previous illnesses were examined. Results 334 patients underwent ECMO: 29 (8.7%) patients experienced intracranial hemorrhage. Among these patients 11 (37.9%) patients received a veno-arterial ECMO and 18 (62.1%) patients received a veno-venous ECMO. The median age was 55 years. The patients were in hospital for an average of 25 days (range 1-77 days). The median duration of ECMO-treatment was 17 days, of which intracranial hemorrhage occurred in median day 12 (range 0 – 40 days). Intracerebral hemorrhage was detected in 13 (44.8%) cases, 7 (3.4%) patients experienced a subdural hematoma, intraventricular hemorrhage occurred in 3 (10.3%) patients and 6 (20.7%) patients experienced a subarachnoid hemorrhage. The mortality rate associated with hemorrhage was 86,2%. Conclusion In conclusion, there is a high frequency of intracranial hemorrhage in patients requiring ECMO. A proportion of these patients shows a rapidly increasing hemorrhage volume, which is associated with a high mortality rate. It is important to identify predictive factors in this patient population in order to improve outcome.

The impact of initial hemorrhage pattern on complications and outcome of non-aneurysmatic spontaneous subarachnoid hemorrhage

Abstract-Text Introduction Spontaneous subrarachnoid hemorrhage (sSAH) is most frequently caused by rupture of an cerebral aneurysm. However, in around 15% of all sSAH the bleeding source cannot be determined in CT-angiography or digital subtraction angiography. Non-aneurysmatic sSAH (nSAH) are known for a milder clinical course, a lower complication rates and a favorable outcome. We report our experience with nSAH to evaluate possible risk factors that might hamper the otherwise good prognosis and analyze the impact of different hemorrhage patterns. Methods Two neurosurgical departments (Geneva and Mainz) included 68 consecutive patients diagnosed with nSAH in our retrospective analysis. The cohort was divided into two subgroups based on initial CT scans: typical perimesencephalic hemorrhage pattern (pSAH) and diffuse hemorrhage pattern (dSAH). Baseline demographics include patients" characteristics and comorbidities. Hunt&amp;Hess score (H&amp;H), Fisher score (FS) and WFNS as well as initial symptoms and complications (vasospasm, hydrocephalus, re-bleeding) were analyzed. The outcome was measured using the modified Rankin Scale (mRS) after 6 months. Results In 20 cases the blood distribution pattern was perimesencephalic and in 48 cases diffuse. In case of dSAH the H&amp;H was significantly higher compared to pSAH (p=0.0042). Risk factors for a worse outcome were hypertension (p=0.03), high age (p=0.0008) and a high WFNS score at admission (p=0.02). The necessity of cerebrospinal fluid drainage was significantly higher in patients with dSAH (n=18) compared to pSAH (n=2)(p=0.03). Twenty patients developed vasospasms. dSAH and pSAH subgroup had a similar risk to develop vasospasm detected in CTA (p=0.77). However, all patients with a symptomatic vasospasm had a diffuse hemorrhage pattern. The prophylaxis with nimodipine did not significantly reduce the risk for vasospasm (p=0.06). Significantly more patients with a dSAH had a high mRS (&gt;3) indicating a worse outcome (p=0.02). Conclusions In case of a nSAH with a diffuse pattern of hemorrhage the risk for complications and unfavorable outcome is higher compared to pSAH. Therefore these patients will benefit from a closer monitoring and a longer hospitalization to be ahead of complications.

The recovery of local brain tissue oxygenation after probe insertion: Preliminary data from an observational study in patients with aneurysmal subarachnoid hemorrhage

Abstract-Text Objective: Measuring brain tissue oxygenation (ptiO2) invasively can support the diagnosis and monitoring of treatment efficacy for delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage (aSAH). While the insertion of the probe is not typically associated with major complications, its impact on early ptiO2 measurements is unclear, leaving uncertainty about the reliability of the measurement. Our aim was to characterize the early development and reliability of ptiO2 values after probe insertion. Methods: PtiO2 data were collected prospectively in 94 patients with aSAH. All ptiO2 values up to 14 days after probe insertion were considered. PtiO2 was summarized in 1-hour medians and synchronized for all patients at the time point of probe insertion. Results: Time to insertion after hemorrhage was 82.5±75.1 hours. Initially low ptiO2 values were observed, followed by a recovery (day 0-2) and a plateau phase (day 3-14). Mean ptiO2 was 14.8±12.7mmHg immediately after probe insertion and increased to 20mmHg after 20 hours. On average, the recovery phase continued until 70 hours after probe insertion. PtiO2 was relatively stable with 25.8±13.9mmHg in the subsequent plateau phase. A recovery followed by a plateau phase was observed independently of the time of placement in the early (0-3 days after hemorrhage), subacute (&gt;3 days, no DCI or before DCI) or post-DCI (after DCI) phase. There was considerable inter-individual variation in the duration of the recovery phase, ranging from 0-92 hours. Conclusion: A recovery phase of ptiO2 values after probe insertion is common and may be considerably longer than previously anticipated. The influence on the detection of DCI during the recovery versus plateau phase is yet unclear and will be object of further analyses. Piecewise regression will be applied to determine the changepoint between recovery and plateau phases more individually. Multivariate analysis will investigate the influence of demography, bleeding characteristics, post-insertion hemorrhage or hypodensities, and early and late brain injury parameters on recovery phase dynamics.

Joint Session Vaskuläre Neurochirurgie und Neurotrauma & Intensivmedizin

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