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Kinaci A, Slot EMH, Kollen M, Germans MR, Amin-Hanjani S, Carlson AP, Majeed K, Depauw PRAM, Robe PA, Regli L, Charbel FT, van Doormaal TPC. Risk Factors and Management of Incisional Cerebrospinal Fluid Leakage After Craniotomy: A Retrospective International Multicenter Study. Neurosurgery 2023; 92:1177-1182. [PMID: 36688661 PMCID: PMC10158880 DOI: 10.1227/neu.0000000000002345] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 11/05/2022] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Incisional cerebrospinal fluid (iCSF) leakage is a serious complication after intradural cranial surgery. OBJECTIVE To determine the incidence and risk factors of iCSF leakage after craniotomy. Secondarily, the complications after iCSF leakage and the success rate of iCSF leakage treatment was studied. METHODS All patients who underwent an intradural cranial surgery from 2017 to 2018 at 5 neurosurgical centers were retrospectively included. Data were retrieved from medical records with 2 months of follow-up. First, univariate regression analyses were performed. Subsequently, identified risk factors were evaluated in a multivariate regression analysis. RESULTS In total 2310 consecutive patients were included. Total iCSF leakage rate was 7.1% (n = 165). Younger age, male, higher body mass index, smoking, infratentorial surgery, and use of a dural substitute were associated with increased iCSF leakage risk, and use of a sealant reduced that risk. The odds for developing a wound infection and/or meningitis were 15 times higher in patients with iCSF leakage compared with patients without leakage. Initial conservative iCSF leakage treatment failed in 48% of patients. In 80% of cases, external cerebrospinal fluid drainage ceased the iCSF leakage. A total of 32% of patients with iCSF leakage required wound revision surgery. CONCLUSION iCSF leakage risk increases by younger age, higher body mass index, smoking, infratentorial craniotomy, and dural substitute use, whereas sealant use reduced the risk for iCSF leakage. The leak increases the risk of postoperative infections. When iCSF leakage occurs, immediate external cerebrospinal fluid drainage or wound revision should be considered.
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Affiliation(s)
- Ahmet Kinaci
- Department of Neurosurgery, Brain Center, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Emma M. H. Slot
- Department of Neurosurgery, Brain Center, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Mare Kollen
- Department of Neurosurgery, Brain Center, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Menno R. Germans
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Sepideh Amin-Hanjani
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Andrew P. Carlson
- Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico, USA
| | - Kashif Majeed
- Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico, USA
| | - Paul R. A. M. Depauw
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
| | - Pierre A. Robe
- Department of Neurosurgery, Brain Center, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Luca Regli
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Fady T. Charbel
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Tristan P. C. van Doormaal
- Department of Neurosurgery, Brain Center, University Medical Centre Utrecht, Utrecht, the Netherlands
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Slot EMH, van Doormaal TPC, van Baarsen KM, Krayenbühl N, Regli L, Germans MR, Hoving EW. Incisional CSF leakage after intradural cranial surgery in children: incidence, risk factors, and complications. J Neurosurg Pediatr 2023; 31:313-320. [PMID: 36738466 DOI: 10.3171/2022.11.peds22421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 11/23/2022] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The risk of cerebrospinal fluid (CSF) leakage after cranial surgery and its associated complications in children are unclear because of variable definitions and the lack of multicenter studies. In this study, the authors aimed to establish the incidence of CSF leakage after intradural cranial surgery in the pediatric population. In addition, they evaluated potential risk factors and complications related to CSF leakage in the pediatric population. METHODS The authors performed an international multicenter retrospective cohort study in three tertiary neurosurgical referral centers. Included were all patients aged 18 years or younger who had undergone cranial surgery to reach the subdural space during the period between 2015 and 2021. Patients who died or were lost to follow-up within 6 weeks after surgery were excluded. The primary outcome measure was the incidence of CSF leakage, defined as leakage through the skin, within 6 weeks after surgery. Univariable and multivariable logistic regression analyses were performed to identify risk factors for and complications related to CSF leakage. RESULTS In total, 759 procedures were identified, performed in 687 individual patients. The incidence of CSF leakage was 7.5% (95% CI 5.7%-9.6%). In the multivariate model, independent risk factors for CSF leakage were hydrocephalus (OR 4.5, 95% CI 2.2-8.9) and craniectomy (OR 7.6, 95% CI 3.0-19.5). Patients with CSF leakage had higher odds of pseudomeningocele (5.7, 95% CI 3.0-10.8), meningitis (21.1, 95% CI 9.5-46.8), and surgical site infection (7.4, 95% CI 2.6-20.8) than patients without leakage. CONCLUSIONS CSF leakage risk in children after cranial surgery, which is comparable to the risk reported in adults, is an event of major concern and has a serious clinical impact.
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Affiliation(s)
- Emma M H Slot
- 1Department of Neurology and Neurosurgery, University Medical Center Utrecht.,2Department of Translational Neuroscience, University Medical Center, Utrecht Brain Center, Utrecht University, Utrecht, The Netherlands
| | - Tristan P C van Doormaal
- 1Department of Neurology and Neurosurgery, University Medical Center Utrecht.,1Department of Neurology and Neurosurgery, University Medical Center Utrecht.,3Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Kirsten M van Baarsen
- 4Department of Neuro-oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands; and
| | - Niklaus Krayenbühl
- 3Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland.,5Division of Pediatric Neurosurgery, University Children's Hospital Zurich, University of Zurich, Switzerland
| | - Luca Regli
- 3Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Menno R Germans
- 3Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Eelco W Hoving
- 1Department of Neurology and Neurosurgery, University Medical Center Utrecht.,4Department of Neuro-oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands; and
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3
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Slot EMH, Bergmann W, Kinaci A, de Boer B, Moayeri N, Redegeld S, van Thoor S, van Doormaal TPC. Histological and magnetic resonance imaging assessment of Liqoseal in a spinal in vivo pig model. Animal Model Exp Med 2023; 6:74-80. [PMID: 36547216 PMCID: PMC9986228 DOI: 10.1002/ame2.12294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 10/31/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Liqoseal (Polyganics, B.V.) is a dural sealant patch for preventing postoperative cerebrospinal fluid (CSF) leakage. It has been extensively tested preclinically and CE (Conformité Européenne) approved for human use after a first cranial in-human study. However, the safety of Liqoseal for spinal application is still unknown. The aim of this study was to assess the safety of spinal Liqoseal application compared with cranial application using histology and magnetic resonance imaging characteristics. METHODS Eight female Dutch Landrace pigs underwent laminectomy, durotomy with standard suturing and Liqoseal application. Three control animals underwent the same procedure without sealant application. The histological characteristics and imaging characteristics of animals with similar survival times were compared to data from a previous cranial porcine model. RESULTS Similar foreign body reactions were observed in spinal and cranial dura. The foreign body reaction consisted of neutrophils and reactive fibroblasts in the first 3 days, changing to a chronic granulomatous inflammatory reaction with an increasing number of macrophages and lymphocytes and the formation of a fibroblast layer on the dura by day 7. Mean Liqoseal plus dura thickness reached a maximum of 1.2 mm (range 0.7-2.0 mm) at day 7. CONCLUSION The spinal dural histological reaction to Liqoseal during the first 7 days was similar to the cranial dural reaction. Liqoseal did not swell significantly in both application areas over time. Given the current lack of a safe and effective dural sealant for spinal application, we propose that an in-human safety study of Liqoseal is the logical next step.
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Affiliation(s)
- Emma M H Slot
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, the Netherlands.,Department of Translational Neuroscience, Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Wilhelmina Bergmann
- Department of Biomolecular Health Sciences, Division of Pathology, Faculty of Veterinary Medicine, Utrecht University, Utrecht, the Netherlands
| | - Ahmet Kinaci
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Bart de Boer
- Department of Neurosurgery, Elizabeth TweeSteden ziekenhuis, Tilburg, the Netherlands
| | - Nizar Moayeri
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | | | - Tristan P C van Doormaal
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, the Netherlands.,Department of Translational Neuroscience, Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands.,Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
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4
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Slot EMH, Colmer N, Serra C, Holzmann D, Regli L, van Doormaal TPC. Ex vivo and in vivo evaluation of transsphenoidal Liqoseal application to prevent cerebrospinal fluid leakage. Acta Neurochir (Wien) 2023; 165:1511-1521. [PMID: 36624231 DOI: 10.1007/s00701-022-05477-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 12/20/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Despite improvements in closure techniques by using a vital nasoseptal flap, the use of sealing materials, and improved neurosurgical techniques, cerebrospinal fluid (CSF) leak after transsphenoidal surgery still is a clinically relevant problem. Liqoseal® (Polyganics bv, Groningen, The Netherlands) is a CE-approved bioresorbable sealant patch for use as an adjunct to standard methods of cranial dural closure to prevent CSF leakage. This study aims to evaluate the application of Liqoseal in transsphenoidal surgery ex vivo and in vivo. METHODS 1. We created an ex vivo setup simulating the sphenoidal anatomy, using a fluid pump and porcine dura positioned on a conus with the anatomical dimensions of the sella to evaluate whether the burst pressure of Liqoseal applied to a bulging surface was above physiological intracranial pressure. Burst pressure was measured with a probe connected to dedicated computer software. Because of the challenging transsphenoidal environment, we tested in 4 groups with varying compression weight and time for the application of Liqoseal. 2. We subsequently describe the application of Liqoseal® in 3 patients during transsphenoidal procedures with intraoperative CSF leakage to prevent postoperative CSF leakage. RESULTS 1. Ex vivo: The overall mean burst pressure in the transsphenoidal setup was 231 (± 103) mmHg. There was no significant difference in mean burst pressure between groups based on application weight and time (p = 0.227). 2. In Vivo: None of the patients had a postoperative CSF leak. No nose passage problems were observed. One patient had a postoperative meningitis and ventriculitis, most likely related to preoperative extensive CSF leakage. Postoperative imaging did not show any local infection, swelling, or other device-related adverse effects. CONCLUSIONS We assess the use of Liqoseal® to seal a dural defect during an endoscopic transsphenoidal procedure as to be likely safe and potentially effective.
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Affiliation(s)
- Emma M H Slot
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Translational Neuroscience, University Medical Center, Utrecht Brain Center, Utrecht University, Utrecht, The Netherlands
| | - Nadia Colmer
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Carlo Serra
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
| | - David Holzmann
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
| | - Tristan P C van Doormaal
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands.
- Department of Translational Neuroscience, University Medical Center, Utrecht Brain Center, Utrecht University, Utrecht, The Netherlands.
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland.
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5
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van Voorst H, Konduri PR, van Poppel LM, van der Steen W, van der Sluijs PM, Slot EMH, Emmer BJ, van Zwam WH, Roos YBWEM, Majoie CBLM, Zaharchuk G, Caan MWA, Marquering HA. Unsupervised Deep Learning for Stroke Lesion Segmentation on Follow-up CT Based on Generative Adversarial Networks. AJNR Am J Neuroradiol 2022; 43:1107-1114. [PMID: 35902122 PMCID: PMC9575413 DOI: 10.3174/ajnr.a7582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 06/02/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND PURPOSE Supervised deep learning is the state-of-the-art method for stroke lesion segmentation on NCCT. Supervised methods require manual lesion annotations for model development, while unsupervised deep learning methods such as generative adversarial networks do not. The aim of this study was to develop and evaluate a generative adversarial network to segment infarct and hemorrhagic stroke lesions on follow-up NCCT scans. MATERIALS AND METHODS Training data consisted of 820 patients with baseline and follow-up NCCT from 3 Dutch acute ischemic stroke trials. A generative adversarial network was optimized to transform a follow-up scan with a lesion to a generated baseline scan without a lesion by generating a difference map that was subtracted from the follow-up scan. The generated difference map was used to automatically extract lesion segmentations. Segmentation of primary hemorrhagic lesions, hemorrhagic transformation of ischemic stroke, and 24-hour and 1-week follow-up infarct lesions were evaluated relative to expert annotations with the Dice similarity coefficient, Bland-Altman analysis, and intraclass correlation coefficient. RESULTS The median Dice similarity coefficient was 0.31 (interquartile range, 0.08-0.59) and 0.59 (interquartile range, 0.29-0.74) for the 24-hour and 1-week infarct lesions, respectively. A much lower Dice similarity coefficient was measured for hemorrhagic transformation (median, 0.02; interquartile range, 0-0.14) and primary hemorrhage lesions (median, 0.08; interquartile range, 0.01-0.35). Predicted lesion volume and the intraclass correlation coefficient were good for the 24-hour (bias, 3 mL; limits of agreement, -64-59 mL; intraclass correlation coefficient, 0.83; 95% CI, 0.78-0.88) and excellent for the 1-week (bias, -4 m; limits of agreement,-66-58 mL; intraclass correlation coefficient, 0.90; 95% CI, 0.83-0.93) follow-up infarct lesions. CONCLUSIONS An unsupervised generative adversarial network can be used to obtain automated infarct lesion segmentations with a moderate Dice similarity coefficient and good volumetric correspondence.
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Affiliation(s)
- H van Voorst
- From the Departments of Radiology and Nuclear Medicine (H.v.V., P.R.K., L.M.v.P., B.J.E., C.B.L.M.M., H.A.M.) .,Biomedical Engineering and Physics (H.v.V., P.R.K., L.M.v.P., M.W.A.C., H.A.M.)
| | - P R Konduri
- From the Departments of Radiology and Nuclear Medicine (H.v.V., P.R.K., L.M.v.P., B.J.E., C.B.L.M.M., H.A.M.).,Biomedical Engineering and Physics (H.v.V., P.R.K., L.M.v.P., M.W.A.C., H.A.M.)
| | - L M van Poppel
- From the Departments of Radiology and Nuclear Medicine (H.v.V., P.R.K., L.M.v.P., B.J.E., C.B.L.M.M., H.A.M.).,Biomedical Engineering and Physics (H.v.V., P.R.K., L.M.v.P., M.W.A.C., H.A.M.)
| | - W van der Steen
- Departments of Neurology (W.v.d.S., P.M.v.d.S.).,Radiology and Nuclear Medicine (W.v.d.S., P.M.v.d.S.), Erasmus University Medical Center, Rotterdam, the Netherlands
| | - P M van der Sluijs
- Departments of Neurology (W.v.d.S., P.M.v.d.S.).,Radiology and Nuclear Medicine (W.v.d.S., P.M.v.d.S.), Erasmus University Medical Center, Rotterdam, the Netherlands
| | - E M H Slot
- Department of Neurology and Neurosurgery (E.M.H.S.), University Medical Center Utrecht, Utrecht, the Netherlands
| | - B J Emmer
- From the Departments of Radiology and Nuclear Medicine (H.v.V., P.R.K., L.M.v.P., B.J.E., C.B.L.M.M., H.A.M.)
| | - W H van Zwam
- Department of Radiology and Nuclear Medicine (W.H.v.Z.), Maastricht University Medical Center, Maastricht, the Netherlands
| | - Y B W E M Roos
- Neurology (Y.B.W.E.M.R.), Faculty of Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - C B L M Majoie
- From the Departments of Radiology and Nuclear Medicine (H.v.V., P.R.K., L.M.v.P., B.J.E., C.B.L.M.M., H.A.M.)
| | - G Zaharchuk
- Department of Radiology (G.Z.), Stanford University, Stanford, California
| | - M W A Caan
- Biomedical Engineering and Physics (H.v.V., P.R.K., L.M.v.P., M.W.A.C., H.A.M.)
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Carlson AP, Slot EMH, van Doormaal TPC, Voormolen EHJ, Dankbaar JW, Depauw P, Brouwers B, Germans MR, Baert E, Vandersteene J, Freyschlag CF, Freyschlag J, Thomé C, Zenga F, Penner F, Abdulazim A, Sabel M, Rapp M, Beez T, Zuccarello M, Sauvageau E, Abdullah K, Welch B, Langer D, Ellis J, Dehdashti A, VanGompel J, Bendok B, Chaichana K, Liu J, Dogan A, Lim MK, Hayden MG. Evaluate the safety and efficacy of dura sealant patch in reducing cerebrospinal fluid leakage following elective cranial surgery (ENCASE II): study protocol for a randomized, two-arm, multicenter trial. Trials 2022; 23:581. [PMID: 35858894 PMCID: PMC9297260 DOI: 10.1186/s13063-022-06490-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 06/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cerebrospinal fluid (CSF) leakage is a frequent and challenging complication in neurosurgery, especially in the posterior fossa, with a prevalence of 8%. It is associated with substantial morbidity and increased healthcare costs. A novel dural sealant patch (LIQOSEAL) was developed for watertight dural closure. The objective of this study is to clinically assess the safety and effectiveness of LIQOSEAL as a means of reducing intra- as well as postoperative CSF leakage in patients undergoing elective posterior fossa intradural surgery with a dural closure procedure compared to the best currently available dural sealants. METHODS We will conduct a two-arm, randomized controlled, multicenter study with a 90-day follow-up. A total of 228 patients will be enrolled in 19 sites, of which 114 will receive LIQOSEAL and 114 an FDA-approved PEG sealant. The composite primary endpoint is defined as intraoperative CSF leakage at PEEP 20 cm H2O, percutaneous CSF leakage within 90 days of, wound infection within 90 days of or pseudomeningocele of more than 20cc on MRI or requiring intervention. We hypothesize that the primary endpoint will not be reached by more than 10 patients (9%) in the investigational arm, which will demonstrate non-inferiority of LIQOSEAL compared to control. DISCUSSION This trial will evaluate whether LIQOSEAL is non-inferior to control as a means of reducing CSF leakage and safety TRIAL REGISTRATION: ClinicalTrials.gov NCT04086550 . Registered on 11 September 2019.
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Affiliation(s)
- Andrew P Carlson
- Department of Neurosurgery, University of New Mexico, 1 UNM, Albuquerque, NM, 87131, USA.
| | - Emma M H Slot
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Translational Neuroscience, University Medical Center Utrecht, Brain Center, Utrecht University, Utrecht, The Netherlands
| | - Tristan P C van Doormaal
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Translational Neuroscience, University Medical Center Utrecht, Brain Center, Utrecht University, Utrecht, The Netherlands.,Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
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Slot EMH, Boer B, Redegeld S, Thoor S, Moayeri N, Slooff W, Schaafsma IA, Meij B, Doormaal TPC. Spinal fixation after laminectomy in pigs prevents postoperative spinal cord injury. Animal Model Exp Med 2022; 5:153-160. [PMID: 35234366 PMCID: PMC9043715 DOI: 10.1002/ame2.12213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 01/06/2022] [Accepted: 01/07/2022] [Indexed: 11/16/2022] Open
Abstract
Background A safe, effective, and ethically sound animal model is essential for preclinical research to investigate spinal medical devices. We report the initial failure of a porcine spinal survival model and a potential solution by fixating the spine. Methods Eleven female Dutch Landrace pigs underwent a spinal lumbar interlaminar decompression with durotomy and were randomized for implantation of a medical device or control group. Magnetic resonance imaging (MRI) was performed before termination. Results Neurological deficits were observed in 6 out of the first 8 animals. Three of these animals were terminated prematurely because they reached the predefined humane endpoint. Spinal cord compression and myelopathy was observed on postoperative MRI imaging. We hypothesized postoperative spinal instability with epidural hematoma, inherent to the biology of the model, and subsequent spinal cord injury as a potential cause. In the subsequent 3 animals, we fixated the spine with Lubra plates. All these animals recovered without neurological deficits. The extent of spinal cord compression on MRI was variable across animals and did not seem to correspond well with neurological outcome. Conclusion This study shows that in a porcine in vivo model of interlaminar decompression and durotomy, fixation of the spine after lumbar interlaminar decompression is feasible and may improve neurological outcomes. Additional research is necessary to evaluate this hypothesis.
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Affiliation(s)
- Emma M. H. Slot
- Department of Neurology and Neurosurgery University Medical Center Utrecht Utrecht The Netherlands
| | - Bart Boer
- Department of Neurosurgery Elizabeth TweeSteden Hospital Tilburg The Netherlands
| | | | - Sander Thoor
- Brain Technology Institute Utrecht The Netherlands
| | - Nizar Moayeri
- Department of Neurology and Neurosurgery University Medical Center Utrecht Utrecht The Netherlands
| | - Willem‐Bart Slooff
- Department of Neurology and Neurosurgery University Medical Center Utrecht Utrecht The Netherlands
| | - Irene A. Schaafsma
- Department of Clinical Sciences Faculty of Veterinary Medicine Utrecht University Utrecht The Netherlands
| | - Björn Meij
- Department of Clinical Sciences Faculty of Veterinary Medicine Utrecht University Utrecht The Netherlands
| | - Tristan P. C. Doormaal
- Department of Neurology and Neurosurgery University Medical Center Utrecht Utrecht The Netherlands
- Department of Neurosurgery Clinical Neuroscience Center University Hospital Zurich Zurich Switzerland
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van Lieshout C, Slot EMH, Kinaci A, Kollen MH, Hoving EW, Frederix GWJ, van Doormaal TPC. Cerebrospinal fluid leakage costs after craniotomy and health economic assessment of incidence reduction from a hospital perspective in the Netherlands. BMJ Open 2021; 11:e052553. [PMID: 34916315 PMCID: PMC8679119 DOI: 10.1136/bmjopen-2021-052553] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES We aim to quantify the cost difference between patients with incisional cerebrospinal fluid (iCSF) leakage and those without after intradural cranial surgery. Second, the potential cost savings per patient when a decrease in iCSF leakage rate would be achieved with and without added costs for preventative measures of various price and efficacy are modelled. DESIGN Health economic assessment from a hospital perspective based on a retrospective cohort study. SETTING Dutch tertiary referral centre. PARTICIPANTS We included 616 consecutive patients who underwent intradural cranial surgery between 1 September 2017 and 1 September 2018. Patients undergoing burr hole surgery or transsphenoidal surgery, or who died within 1 month after surgery or were lost to follow-up were excluded. PRIMARY AND SECONDARY OUTCOME MEASURES Outcomes of the cost analysis include a detailed breakdown of mean costs per patient for patients with postoperative iCSF leakage and patients without, and the mean cost difference. For the scenario analyses the outcomes are the potential cost savings per 1000 patients when a decrease in iCSF leakage would be achieved. RESULTS Mean cost difference between patients with and without iCSF leakage was €9665 (95%CI, €5125 to €14 205). The main cost driver was hospital stay with a difference of 8.5 days. A 25% incidence reduction would result in a mean cost saving of -€94 039 (95% CI, -€218 258 to -€7077) per 1000 patients. A maximum cost reduction of -€653 025 (95% CI, -€1 204 243 to -€169 120) per 1000 patients could be achieved if iCSF leakage would be reduced with 75% in all patients, with 72 cases of iCSF leakage avoided. CONCLUSIONS Postoperative iCSF leakage after intradural cranial surgery increases healthcare costs significantly and substantially. From a health economic perspective preventative measures to avoid iCSF leakage should be pursued.
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Affiliation(s)
- Chris van Lieshout
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Emma M H Slot
- Neurology and Neurosurgery, University Medical Centre Utrecht Brain Centre, Utrecht, The Netherlands
- Translational Neuroscience, University Medical Centre Utrecht Brain Centre, Utrecht, The Netherlands
| | - Ahmet Kinaci
- Neurology and Neurosurgery, University Medical Centre Utrecht Brain Centre, Utrecht, The Netherlands
| | - Mare H Kollen
- Neurology and Neurosurgery, University Medical Centre Utrecht Brain Centre, Utrecht, The Netherlands
| | - Eelco W Hoving
- Neurology and Neurosurgery, University Medical Centre Utrecht Brain Centre, Utrecht, The Netherlands
- Neuro-oncology, Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Geert W J Frederix
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Tristan P C van Doormaal
- Neurology and Neurosurgery, University Medical Centre Utrecht Brain Centre, Utrecht, The Netherlands
- Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
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Hulshof HM, Slot EMH, Lequin M, Breuillard D, Boddaert N, Jozwiak S, Kotulska K, Riney K, Feucht M, Samueli S, Scholl T, Krsek P, Benova B, Braun KPJ, Jansen FE, Nabbout R. Fetal Brain Magnetic Resonance Imaging Findings Predict Neurodevelopment in Children with Tuberous Sclerosis Complex. J Pediatr 2021; 233:156-162.e2. [PMID: 33640330 DOI: 10.1016/j.jpeds.2021.02.060] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 02/19/2021] [Accepted: 02/22/2021] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To correlate fetal brain magnetic resonance imaging (MRI) findings with epilepsy characteristics and neurodevelopment at 2 years of age in children with tuberous sclerosis complex (TSC) to improve prenatal counseling. STUDY DESIGN This retrospective cohort study was performed in a collaboration between centers of the EPISTOP consortium. We included children with definite TSC, fetal MRIs, and available follow-up data at 2 years of age. A pediatric neuroradiologist masked to the patient's clinical characteristics evaluated all fetal MRIs. MRIs were categorized for each of the 10 brain lobes as score 0: no (sub)cortical lesions or doubt; score 1: a single small lesion; score 2: more than one small lesion or at least one large lesion (>5 mm). Neurologic manifestations were correlated to lesion sum scores. RESULTS Forty-one children were included. Median gestational age at MRI was 33.3 weeks; (sub)cortical lesions were detected in 97.6%. Mean lesion sum score was 4.5. At 2 years, 58.5% of patients had epilepsy and 22% had drug-resistant epilepsy. Cognitive, language, and motor development were delayed in 38%, 81%, and 50% of patients, respectively. Autism spectrum disorder (ASD) was diagnosed in 20.5%. Fetal MRI lesion sum scores were significantly associated with cognitive and motor development, and with ASD diagnosis, but not with epilepsy characteristics. CONCLUSIONS Fetal cerebral lesion scores correlate with neurodevelopment and ASD at 2 years in children with TSC.
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Affiliation(s)
- Hanna M Hulshof
- Department of Pediatric Neurology, University Medical Center, Utrecht Brain Center, Utrecht, the Netherlands (Member of the European Reference Network EpiCARE).
| | - Emma M H Slot
- Department of Pediatric Neurology, University Medical Center, Utrecht Brain Center, Utrecht, the Netherlands (Member of the European Reference Network EpiCARE)
| | - Maarten Lequin
- Department of Radiology, University Medical Center, Utrecht, the Netherlands
| | - Delphine Breuillard
- Department of Pediatric Neurology, Necker Enfants Maladies Hospital, Paris, France (Member of the European Reference Network EpiCARE)
| | - Nathalie Boddaert
- Department of Pediatric Radiology, Necker Enfants Maladies Hospital, Paris, France
| | - Sergiusz Jozwiak
- Instytut Pomnik-Centrum Zdrowia Dziecka, The Children's Memorial Health Institute, Warsaw, Poland (Member of the European Reference Network EpiCARE); Department of Child Neurology, Medical University of Warsaw, Warsaw, Poland
| | - Katarzyna Kotulska
- Instytut Pomnik-Centrum Zdrowia Dziecka, The Children's Memorial Health Institute, Warsaw, Poland (Member of the European Reference Network EpiCARE)
| | - Kate Riney
- Neurosciences Unit, Queensland Children's Hospital/University of Queensland School of Medicine, Brisbane, Australia
| | - Martha Feucht
- Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Vienna, Austria (Member of the European Reference Network EpiCARE)
| | - Sharon Samueli
- Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Vienna, Austria (Member of the European Reference Network EpiCARE)
| | - Theresa Scholl
- Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Vienna, Austria (Member of the European Reference Network EpiCARE)
| | - Pavel Krsek
- Department of Pediatric Neurology, Motol University Hospital, Prague, Czech Republic
| | - Barbora Benova
- Department of Pediatric Neurology, Motol University Hospital, Prague, Czech Republic
| | - Kees P J Braun
- Department of Pediatric Neurology, University Medical Center, Utrecht Brain Center, Utrecht, the Netherlands (Member of the European Reference Network EpiCARE)
| | - Floor E Jansen
- Department of Pediatric Neurology, University Medical Center, Utrecht Brain Center, Utrecht, the Netherlands (Member of the European Reference Network EpiCARE)
| | - Rima Nabbout
- Department of Pediatric Neurology, Necker Enfants Maladies Hospital, Paris, France (Member of the European Reference Network EpiCARE)
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Slot EMH, van Baarsen KM, Hoving EW, Zuithoff NPA, van Doormaal TPC. Cerebrospinal fluid leakage after cranial surgery in the pediatric population-a systematic review and meta-analysis. Childs Nerv Syst 2021; 37:1439-1447. [PMID: 33538867 PMCID: PMC8084768 DOI: 10.1007/s00381-021-05036-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 01/01/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Cerebrospinal fluid (CSF) leakage is a common complication after neurosurgical intervention. It is associated with substantial morbidity and increased healthcare costs. The current systematic review and meta-analysis aim to quantify the incidence of cerebrospinal fluid leakage in the pediatric population and identify its risk factors. METHODS The authors followed the PRISMA guidelines. The Embase, PubMed, and Cochrane database were searched for studies reporting CSF leakage after intradural cranial surgery in patients up to 18 years old. Meta-analysis of incidences was performed using a generalized linear mixed model. RESULTS Twenty-six articles were included in this systematic review. Data were retrieved of 2929 patients who underwent a total of 3034 intradural cranial surgeries. Surprisingly, only four of the included articles reported their definition of CSF leakage. The overall CSF leakage rate was 4.4% (95% CI 2.6 to 7.3%). The odds of CSF leakage were significantly greater for craniectomy as opposed to craniotomy (OR 4.7, 95% CI 1.7 to 13.4) and infratentorial as opposed to supratentorial surgery (OR 5.9, 95% CI 1.7 to 20.6). The odds of CSF leakage were significantly lower for duraplasty use versus no duraplasty (OR 0.41 95% CI 0.2 to 0.9). CONCLUSION The overall CSF leakage rate after intradural cranial surgery in the pediatric population is 4.4%. Risk factors are craniectomy and infratentorial surgery. Duraplasty use is negatively associated with CSF leak. We suggest defining a CSF leak as "leakage of CSF through the skin," as an unambiguous definition is fundamental for future research.
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Affiliation(s)
- Emma M. H. Slot
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Kirsten M. van Baarsen
- Department of Neuro-oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Eelco W. Hoving
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands ,Department of Neuro-oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Nicolaas P. A. Zuithoff
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Tristan P. C van Doormaal
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands ,Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
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11
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Bourcier R, Lindgren A, Desal H, L'Allinec V, Januel AC, Koivisto T, Jääskeläinen JE, Slot EMH, Mensing L, Zuithoff NPA, Milot G, Algra A, Rinkel GJE, Ruigrok Y. Concordance in Aneurysm Size at Time of Rupture in Familial Intracranial Aneurysms. Stroke 2019; 50:504-506. [PMID: 30602357 DOI: 10.1161/strokeaha.118.021911] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Intracranial aneurysm (IA) size and location are important determinants of aneurysm rupture risk. In familial IAs there is concordance of location; however, if such concordance exists for size is unknown. We analyzed the concordance of aneurysm size at time of rupture in familial IAs. Methods- In pairs of affected relatives with aneurysmal subarachnoid hemorrhage, the ratio between the largest and the smallest aneurysm size at time of rupture was calculated. We also compared the proportion of families in which both IAs ruptured at a size < or ≥7 mm with the proportion of families in which one IA ruptured at <7 mm and another ≥7 mm. We calculated the repeatability with corresponding 95% CI for aneurysm size at time of rupture. Results- About 130 patients from 64 families were included. Of the 68 affected pairs 18 (26%) had a ratio ≤1.2, 38 (57%) had a ratio >1.2, and 12 (17%) had a ratio ≥3. We found no difference between the proportion of families (n=31; 49%) who both had IA at time of rupture <7 mm (n=20; 31%) or both ≥7 mm (n=11; 18%) and the proportion of those families with one patient with an IA <7 mm and another with an IA ≥7 mm (n=33; 51%; P=0.86). Overall, the repeatability in aneurysm size at rupture within familial IAs was 0.10 (95% CI, 0-0.35). Conclusions- There is no good concordance in aneurysm size at rupture within familial IAs. These data suggest that size of a ruptured IA in a family member should not significantly impact on the management of a familial unruptured IA in a relative.
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Affiliation(s)
- Romain Bourcier
- From the INSERM, CNRS, Université de Nantes, l'institut du Thorax, France (R.B., H.D., V.L.).,Department of Neuroradiology, CHU Nantes, France (R.B., H.D., V.L.)
| | | | - Hubert Desal
- From the INSERM, CNRS, Université de Nantes, l'institut du Thorax, France (R.B., H.D., V.L.).,Department of Neuroradiology, CHU Nantes, France (R.B., H.D., V.L.)
| | - Vincent L'Allinec
- From the INSERM, CNRS, Université de Nantes, l'institut du Thorax, France (R.B., H.D., V.L.).,Department of Neuroradiology, CHU Nantes, France (R.B., H.D., V.L.)
| | - Anne Christine Januel
- Diagnostic and Interventional Neuroradiology, University Hospital, Toulouse, France (A.C.J.)
| | | | | | - Emma M H Slot
- Brain Center Rudolf Magnus, Neurology and Neurosurgery, University Medical Center Utrecht, the Netherlands (E.M.H.S., L.M., A.A., G.J.E.R., Y.R.)
| | - Liselore Mensing
- Brain Center Rudolf Magnus, Neurology and Neurosurgery, University Medical Center Utrecht, the Netherlands (E.M.H.S., L.M., A.A., G.J.E.R., Y.R.)
| | - Nicolaas P A Zuithoff
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands (N.P.A.Z., A.A.)
| | - Geneviève Milot
- Research Center of the Centre Hospitalier Universitaire, Quebec City, Canada (G.M.)
| | - Ale Algra
- Brain Center Rudolf Magnus, Neurology and Neurosurgery, University Medical Center Utrecht, the Netherlands (E.M.H.S., L.M., A.A., G.J.E.R., Y.R.).,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands (N.P.A.Z., A.A.)
| | - Gabriël J E Rinkel
- Brain Center Rudolf Magnus, Neurology and Neurosurgery, University Medical Center Utrecht, the Netherlands (E.M.H.S., L.M., A.A., G.J.E.R., Y.R.)
| | - Ynte Ruigrok
- Brain Center Rudolf Magnus, Neurology and Neurosurgery, University Medical Center Utrecht, the Netherlands (E.M.H.S., L.M., A.A., G.J.E.R., Y.R.)
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12
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Slot EMH, Rinkel GJE, Algra A, Ruigrok YM. Patient and aneurysm characteristics in familial intracranial aneurysms. A systematic review and meta-analysis. PLoS One 2019; 14:e0213372. [PMID: 30958821 PMCID: PMC6453525 DOI: 10.1371/journal.pone.0213372] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 02/19/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND PURPOSE Patient and aneurysm characteristics have been reported to differ between patients with familial and non-familial intracranial aneurysms (IAs), although results are inconsistent. We systematically reviewed and meta-analyzed the literature to identify and quantify patient- and aneurysm characteristics associated with familial IAs. METHODS We searched PubMed and EMBASE for case-control and cohort studies comparing patient- and aneurysm characteristics between familial and non-familial IAs. Two observers independently assessed study eligibility and appraised quality with the Newcastle Ottawa Scale. With univariable weighted linear regression analysis we calculated β-coefficients with corresponding 95% confidence intervals (CIs) for ruptured and unruptured IAs combined and for ruptured IAs only. Heterogeneity was assessed with Higgins I2. RESULTS A total of 15 articles were included in the meta-analysis in which 16,346 patients were analyzed with a total of 14,225 IAs. For ruptured and unruptured IAs combined, multiple IAs were more prevalent in familial (28.5%) than in non-familial IAs (20.4%; β = 0.10, 95% CI, 0.04 to 0.16; I2 0%). For ruptured IAs only, in familial patients IAs were more prevalent on the middle cerebral artery (41.1% versus 29.5%; β = 0.12, 95% CI, 0.01 to 0.24; I2 12%) and ruptured at a younger age (46.5 years versus 50.8 years; β = -5.00, 95% CI, -9.31 to -0.69; I2 98%) than in non-familial patients. No significant differences were found for the proportion of women, size of the aneurysm at time of rupture, smoking or hypertension. CONCLUSION These results suggest that characteristics of familial and non-familial IAs show considerable overlap, yet differ on specific aspects. However, results for age at rupture showed considerable heterogeneity. These findings should be taken into consideration for future etiological research into IAs.
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Affiliation(s)
- Emma M. H. Slot
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center, Utrecht, the Netherlands
| | - Gabriel J. E. Rinkel
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center, Utrecht, the Netherlands
| | - Ale Algra
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center, Utrecht, the Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, the Netherlands
| | - Ynte M. Ruigrok
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center, Utrecht, the Netherlands
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