1
|
Thomson BR, Schwendinger N, Beckmann K, Gentinetta T, Couto D, Wymann S, Verdon V, Buzzi RM, Akeret K, Kronen PW, Weinberger EM, Held U, Seehusen F, Richter H, Schaer DJ, Hugelshofer M. Haptoglobin Attenuates Cerebrospinal Fluid Hemoglobin-Induced Neurological Deterioration in Sheep. Transl Stroke Res 2024:10.1007/s12975-024-01254-9. [PMID: 38652234 DOI: 10.1007/s12975-024-01254-9] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 04/10/2024] [Accepted: 04/15/2024] [Indexed: 04/25/2024]
Abstract
Secondary brain injury (SBI) occurs with a lag of several days post-bleeding in patients with aneurysmal subarachnoid hemorrhage (aSAH) and is a strong contributor to mortality and long-term morbidity. aSAH-SBI coincides with cell-free hemoglobin (Hb) release into the cerebrospinal fluid. This temporal association and convincing pathophysiological concepts suggest that CSF-Hb could be a targetable trigger of SBI. However, sparse experimental evidence for Hb's neurotoxicity in vivo defines a significant research gap for clinical translation. We modeled the CSF-Hb exposure observed in aSAH patients in conscious sheep, which allowed us to assess neurological functions in a gyrencephalic species. Twelve animals were randomly assigned for 3-day bi-daily intracerebroventricular (ICV) injections of either Hb or Hb combined with the high-affinity Hb scavenger protein haptoglobin (Hb-Hp, CSL888). Repeated CSF sampling confirmed clinically relevant CSF-Hb concentrations. This prolonged CSF-Hb exposure over 3 days resulted in disturbed movement activity, reduced food intake, and impaired observational neuroscores. The Hb-induced neurotoxic effects were significantly attenuated when Hb was administered with equimolar haptoglobin. Preterminal magnetic resonance imaging (MRI) showed no CSF-Hb-specific structural brain alterations. In both groups, histology demonstrated an inflammatory response and revealed enhanced perivascular histiocytic infiltrates in the Hb-Hp group, indicative of adaptive mechanisms. Heme exposure in CSF and iron deposition in the brain were comparable, suggesting comparable clearance efficiency of Hb and Hb-haptoglobin complexes from the intracranial compartment. We identified a neurological phenotype of CSF-Hb toxicity in conscious sheep, which is rather due to neurovascular dysfunction than structural brain injury. Haptoglobin was effective at attenuating CSF-Hb-induced neurological deterioration, supporting its therapeutic potential.
Collapse
Affiliation(s)
- Bart R Thomson
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital and University of Zurich, Zurich, Switzerland
- Division of Internal Medicine, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Nina Schwendinger
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Katrin Beckmann
- Neurology Service, Department of Small Animals, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | - Thomas Gentinetta
- CSL Biologics Research Centre, Swiss Institute for Translational and Entrepreneurial Medicine, CSL, sitem-insel, Bern, Switzerland
| | - Daniel Couto
- CSL Biologics Research Centre, Swiss Institute for Translational and Entrepreneurial Medicine, CSL, sitem-insel, Bern, Switzerland
| | - Sandra Wymann
- CSL Biologics Research Centre, Swiss Institute for Translational and Entrepreneurial Medicine, CSL, sitem-insel, Bern, Switzerland
| | - Valérie Verdon
- CSL Biologics Research Centre, Swiss Institute for Translational and Entrepreneurial Medicine, CSL, sitem-insel, Bern, Switzerland
| | - Raphael M Buzzi
- Division of Internal Medicine, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Kevin Akeret
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Peter W Kronen
- Veterinary Anaesthesia Services - International, Winterthur, Switzerland
- Center for Applied Biotechnology and Molecular Medicine (CABMM), University of Zurich, Zurich, Switzerland
| | - Eva M Weinberger
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Ulrike Held
- Department of Biostatistics and Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Frauke Seehusen
- Laboratory of Animal Model Pathology, Institute of Veterinary Pathology, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | - Henning Richter
- Center for Applied Biotechnology and Molecular Medicine (CABMM), University of Zurich, Zurich, Switzerland
- Diagnostic Imaging Research Unit (DIRU), Clinic for Diagnostic Imaging, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | - Dominik J Schaer
- Division of Internal Medicine, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Michael Hugelshofer
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital and University of Zurich, Zurich, Switzerland.
- Center for Applied Biotechnology and Molecular Medicine (CABMM), University of Zurich, Zurich, Switzerland.
| |
Collapse
|
2
|
Tachatos N, Willms JF, Gerlt MS, Kuruvithadam K, Hugelshofer M, Akeret K, Deuel J, Keller E, Schmid Daners M. OxyHbMeter-a novel bedside medical device for monitoring cell-free hemoglobin in the cerebrospinal fluid-proof of principle. Front Med Technol 2024; 6:1274058. [PMID: 38666067 PMCID: PMC11043468 DOI: 10.3389/fmedt.2024.1274058] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 01/15/2024] [Indexed: 04/28/2024] Open
Abstract
Delayed cerebral ischemia (DCI) occurs in up to one third of patients suffering from aneurysmal subarachnoid hemorrhage (aSAH). Untreated, it leads to secondary cerebral infarctions and is frequently associated with death or severe disability. After aneurysm rupture, erythrocytes in the subarachnoid space lyse and liberate free hemoglobin (Hb), a key driver for the development of DCI. Hemoglobin in the cerebrospinal fluid (CSF-Hb) can be analyzed through a two-step procedure of centrifugation to exclude intact erythrocytes and subsequent spectrophotometric quantification. This analysis can only be done in specialized laboratories but not at the bedside in the intensive care unit. This limits the number of tests done, increases the variability of the results and restricts accuracy. Bedside measurements of CSF-Hb as a biomarker with a point of care diagnostic test system would allow for a continuous monitoring for the risk of DCI in the individual patient. In this study, a microfluidic chip was explored that allows to continuously separate blood particles from CSF or plasma based on acoustophoresis. An in vitro test bench was developed to test in-line measurements with the developed microfluidic chip and a spectrometer. The proof of principle for a continuous particle separation device has been established with diluted blood and CSF samples from animals and aSAH patients, respectively. Processing 1 mL of blood in our microfluidic device was achieved within around 70 min demonstrating only minor deviations from the gold standard centrifugation (7% average error of patient samples), while saving several hours of processing time and additionally the reduction of deviations in the results due to manual labor.
Collapse
Affiliation(s)
- Nikolaos Tachatos
- Product Development Group Zurich, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Jan Folkard Willms
- Neurointensive Care Unit, Department of Neurosurgery and Institute of Intensive Care Medicine, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | | | - Kiran Kuruvithadam
- Product Development Group Zurich, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Michael Hugelshofer
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Kevin Akeret
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Jeremy Deuel
- Department of Medical Oncology and Haematology Clinic, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Emanuela Keller
- Neurointensive Care Unit, Department of Neurosurgery and Institute of Intensive Care Medicine, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Marianne Schmid Daners
- Department of Mechanical and Process Engineering, Institute for Dynamic Systems and Control, ETH Zurich, Zurich, Switzerland
| |
Collapse
|
3
|
Stienen MN, Akeret K, Vasella F, Velz J, Jehli E, Voglis S, Bichsel O, Smoll NR, Bozinov O, Regli L, Germans MR. COveRs to impRove EsthetiC ouTcome after Surgery for Chronic subdural hemAtoma by buRr hole trepanation-Results of a Swiss Single-Blinded, Randomized Controlled Trial. Neurosurgery 2023:00006123-990000000-00990. [PMID: 38059611 DOI: 10.1227/neu.0000000000002778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 10/09/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Burr hole trepanation to evacuate chronic subdural hematoma (cSDH) results in bony skull defects that can lead to skin depressions. We intend to study the effect of burr hole covers to prevent skin depressions and improve the esthetic result. METHODS In a randomized trial, we enrolled adult patients with symptomatic cSDH. Patients received burr hole trepanation with (intervention) vs without burr hole covers (control) in a 1:1 ratio. Patients requiring evacuation of bilateral cSDHs served as their internal control. Primary outcome was satisfaction with the esthetic result of the scar, measured from 0 (dissatisfied) to 10 (very satisfied) on the Esthetic Numeric Analog (ANA) scale at 90 days. Secondary outcomes included ANA scale, rates of skin depression, complications, as well as neurological, disability, and health-related quality of life outcomes until 12 months. RESULTS We included 78 patients (55 with unilateral and 23 with bilateral cSDH; median age 78 years, 83% male) between 03/2019 and 05/2021, 50 trepanations for the intervention and 51 for the control group. In an intention-to-treat analysis, the ANA scale scores were 9.0 (intervention) and 8.5 (control arm) at 90 days (P = .498). At 12 months, the ANA scale scores were 9.0 and 8.0 for the intervention and control groups, respectively (P = .183). Skin depressions over the frontal burr hole were noted by 35% (intervention) and 63% (control) of patients at 90 days (P = .009) and by 35% and 79% (P < .001) at 12 months, respectively. There were no differences in complications, neurological, disability, and health-related quality of life outcomes. CONCLUSION Satisfaction with the esthetic result of the scar was inherently high. This study does not show evidence for improvement on the ANA scale by applying a burr hole cover. The application of burr hole covers resulted in less skin depressions and did not negatively affect complication rates or outcomes.
Collapse
Affiliation(s)
- Martin N Stienen
- Department of Neurosurgery, Kantonsspital St.Gallen, St. Gallen, Switzerland
- Department of Neurosurgery, University Hospital Zurich, Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Kevin Akeret
- Department of Neurosurgery, University Hospital Zurich, Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Flavio Vasella
- Department of Neurosurgery, University Hospital Zurich, Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Julia Velz
- Department of Neurosurgery, University Hospital Zurich, Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Elisabeth Jehli
- Department of Neurosurgery, University Hospital Zurich, Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
- Translational Research Center, University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Stefanos Voglis
- Department of Neurosurgery, University Hospital Zurich, Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Oliver Bichsel
- Department of Neurosurgery, University Hospital Zurich, Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Nicolas R Smoll
- School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Oliver Bozinov
- Department of Neurosurgery, Kantonsspital St.Gallen, St. Gallen, Switzerland
- Department of Neurosurgery, University Hospital Zurich, Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, University Hospital Zurich, Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Menno R Germans
- Department of Neurosurgery, University Hospital Zurich, Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| |
Collapse
|
4
|
Thomson BR, Gürlek F, Buzzi RM, Schwendinger N, Keller E, Regli L, van Doormaal TP, Schaer DJ, Hugelshofer M, Akeret K. Clinical potential of automated convolutional neural network-based hematoma volumetry after aneurysmal subarachnoid hemorrhage. J Stroke Cerebrovasc Dis 2023; 32:107357. [PMID: 37734180 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107357] [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: 06/08/2023] [Revised: 09/08/2023] [Accepted: 09/11/2023] [Indexed: 09/23/2023] Open
Abstract
OBJECTIVES Cerebrospinal fluid hemoglobin has been positioned as a potential biomarker and drug target for aneurysmal subarachnoid hemorrhage-related secondary brain injury (SAH-SBI). The maximum amount of hemoglobin, which may be released into the cerebrospinal fluid, is defined by the initial subarachnoid hematoma volume (ISHV). In patients without external ventricular or lumbar drain, there remains an unmet clinical need to predict the risk for SAH-SBI. The aim of this study was to explore automated segmentation of ISHV as a potential surrogate for cerebrospinal fluid hemoglobin to predict SAH-SBI. METHODS This study is based on a retrospective analysis of imaging and clinical data from 220 consecutive patients with aneurysmal subarachnoid hemorrhage collected over a five-year period. 127 annotated initial non-contrast CT scans were used to train and test a convolutional neural network to automatically segment the ISHV in the remaining cohort. Performance was reported in terms of Dice score and intraclass correlation. We characterized the associations between ISHV and baseline cohort characteristics, SAH-SBI, ventriculoperitoneal shunt dependence, functional outcome, and survival. Established clinical (World Federation of Neurosurgical Societies, Hunt & Hess) and radiological (modified Fisher, Barrow Neurological Institute) scores served as references. RESULTS A strong volume agreement (0.73 Dice, range 0.43 - 0.93) and intraclass correlation (0.89, 95% CI, 0.81-0.94) were shown. While ISHV was not associated with the use of antithrombotics or cardiovascular risk factors, there was strong evidence for an association with a lower Glasgow Coma Scale at hospital admission. Aneurysm size and location were not associated with ISHV, but the presence of intracerebral or intraventricular hemorrhage were independently associated with higher ISHV. Despite strong evidence for a positive association between ISHV and SAH-SBI, the discriminatory ability of ISHV for SAH-SBI was insufficient. The discriminatory ability of ISHV was, however, higher regarding ventriculoperitoneal shunt dependence and functional outcome at three-months follow-up. Multivariate survival analysis provided strong evidence for an independent negative association between survival probability and both ISHV and intraventricular hemorrhage. CONCLUSIONS The proposed algorithm demonstrates strong performance in volumetric segmentation of the ISHV on the admission CT. While the discriminatory ability of ISHV for SAH-SBI was similar to established clinical and radiological scores, it showed a high discriminatory ability for ventriculoperitoneal shunt dependence and functional outcome at three-months follow-up.
Collapse
Affiliation(s)
- Bart R Thomson
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital und University of Zurich, Rämistrasse 100, Zurich CH-8091, Switzerland; Division of Internal Medicine, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Firat Gürlek
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital und University of Zurich, Rämistrasse 100, Zurich CH-8091, Switzerland; Division of Internal Medicine, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Raphael M Buzzi
- Division of Internal Medicine, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Nina Schwendinger
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital und University of Zurich, Rämistrasse 100, Zurich CH-8091, Switzerland
| | - Emanuela Keller
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital und University of Zurich, Rämistrasse 100, Zurich CH-8091, Switzerland; Neurointensive Care Unit, Department of Neurosurgery, and Institute of Intensive Care Medicine, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital und University of Zurich, Rämistrasse 100, Zurich CH-8091, Switzerland
| | - Tristan Pc van Doormaal
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital und University of Zurich, Rämistrasse 100, Zurich CH-8091, Switzerland; 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
| | - Dominik J Schaer
- Division of Internal Medicine, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Michael Hugelshofer
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital und University of Zurich, Rämistrasse 100, Zurich CH-8091, Switzerland
| | - Kevin Akeret
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital und University of Zurich, Rämistrasse 100, Zurich CH-8091, Switzerland.
| |
Collapse
|
5
|
Akeret K, Weller M, Krayenbühl N. The anatomy of neuroepithelial tumours. Brain 2023:7171408. [PMID: 37201913 PMCID: PMC10393414 DOI: 10.1093/brain/awad138] [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: 10/01/2022] [Revised: 04/10/2023] [Accepted: 04/12/2023] [Indexed: 05/20/2023] Open
Abstract
Many neurological conditions conceal specific anatomical patterns. Their study contributes to the understanding of disease biology and to tailored diagnostics and therapy. Neuroepithelial tumours exhibit distinct anatomical phenotypes and spatiotemporal dynamics that differ from those of other brain tumours. Brain metastases display a preference for the cortico-subcortical boundaries of watershed areas and have a predominantly spherical growth. Primary CNS lymphomas localize to the white matter and generally invade along fibre tracts. In neuroepithelial tumours, topographic probability mapping and unsupervised topological clustering have identified an inherent radial anatomy and adherence to ventriculopial configurations of specific hierarchical orders. Spatiotemporal probability and multivariate survival analyses have identified a temporal and prognostic sequence underlying the anatomical phenotypes of neuroepithelial tumours. Gradual neuroepithelial de-differentiation and declining prognosis follow (i) an expansion into higher order radial units; (ii) a subventricular spread; and (iii) the presence of mesenchymal patterns (expansion along white matter tracts, leptomeningeal or perivascular invasion, CSF spread). While different pathophysiological hypotheses have been proposed, the cellular and molecular mechanisms dictating this anatomical behaviour remain largely unknown. Here we adopt an ontogenetic approach towards the understanding of neuroepithelial tumour anatomy. Contemporary perception of histo- and morphogenetic processes during neurodevelopment permit us to conceptualize the architecture of the brain into hierarchically organized radial units. The anatomical phenotypes in neuroepithelial tumours and their temporal and prognostic sequences share remarkable similarities with the ontogenetic organization of the brain and the anatomical specifications that occur during neurodevelopment. This macroscopic coherence is reinforced by cellular and molecular observations that the initiation of various neuroepithelial tumours, their intratumoural hierarchy and tumour progression are associated with the aberrant reactivation of surprisingly normal ontogenetic programs. Generalizable topological phenotypes could provide the basis for an anatomical refinement of the current classification of neuroepithelial tumours. In addition, we have proposed a staging system for adult-type diffuse gliomas that is based on the prognostically critical steps along the sequence of anatomical tumour progression. Considering the parallels in anatomical behaviour between different neuroepithelial tumours, analogous staging systems may be implemented for other neuroepithelial tumour types and subtypes. Both the anatomical stage of a neuroepithelial tumour and the spatial configuration of its hosting radial unit harbour the potential to stratify treatment decisions at diagnosis and during follow-up. More data on specific neuroepithelial tumour types and subtypes are needed to increase the anatomical granularity in their classification and to determine the clinical impact of stage-adapted and anatomically tailored therapy and surveillance.
Collapse
Affiliation(s)
- Kevin Akeret
- Department of Neurosurgery, Clinical Neuroscience Centre, University Hospital Zurich and University of Zurich, 8091 Zurich, Switzerland
| | - Michael Weller
- Department of Neurology, Clinical Neuroscience Centre, University Hospital Zurich and University of Zurich, 8091 Zurich, Switzerland
| | - Niklaus Krayenbühl
- Division of Paediatric Neurosurgery, University Children's Hospital, 8032 Zurich, Switzerland
| |
Collapse
|
6
|
Wildi S, Nager S, Akeret K, Özkaratufan S, Krayenbühl N, Bozinov O, Regli L, Velz J. Impact of Long-Term Antithrombotic and Statin Therapy on the Clinical Outcome in Patients with Cavernous Malformations of the Central Nervous System: A Single-Center Case Series of 428 Patients. Cerebrovasc Dis 2023; 52:634-642. [PMID: 36944322 PMCID: PMC10906472 DOI: 10.1159/000529511] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 01/23/2023] [Indexed: 03/23/2023] Open
Abstract
INTRODUCTION Literature regarding the safety and efficacy of antithrombotic (antiplatelet or anticoagulant) therapy and statins in patients with cavernous malformations (CMs) of the central nervous system is sparse, resulting in uncertainty about its use in clinical practice. The aim of this study was to analyze the impact of antithrombotic therapy and statins on the risk of hemorrhage and focal neurological deficit in patients with CMs. METHODS The authors' institutional database was screened for all patients with CMs of the central nervous system treated at their institution between 2006 and 2018. Patients with radiological and/or histological diagnosis of CMs, clinical baseline characteristics, available patient's medication history, and follow-up data were included in this study. Time-to-event probability (hemorrhage or focal neurological deficit) as well as the number of events (hemorrhage or focal neurological deficit) during follow-up were assessed in patients who were categorized according to their medical treatment (antithrombotic therapy, statins, combined therapy, or no treatment). RESULTS Four hundred twenty-eight patients with CMs were eligible and included in the final analysis. Sixty-nine (16.1%) patients were on long-term antithrombotic therapy and 46 (10.6%) on long-term statins, of whom 31 patients were on a combination of both. The probability of experiencing first hemorrhage or focal neurological deficit was less likely in patients on antiplatelet therapy (HR 0.09, 95% CI 0.021-0.39, p = 0.001), anticoagulant therapy (HR 0.12, 95% CI 0.016-0.85, p = 0.034), or the combination thereof (HR 0.12, 95% CI 0.016-0.93, p = 0.043) compared to patients with no antithrombotic treatment. The number of hemorrhages and focal neurological deficits were significantly lower in patients on antithrombotic therapy compared to patients on no treatment during follow-up. In patients on statins alone, the time-to-event probability was comparable to that of patients on no treatment (HR 0.91, 95% CI 0.438-1.91, p = 0.812), and the number of events was similar to patients on no treatment. CONCLUSION The results of our study provide further evidence that antithrombotic therapy alone or in combination with statins in patients with CMs of the central nervous system does not increase the risk of hemorrhage or focal neurological deficit but, on the contrary, may have some benefit.
Collapse
Affiliation(s)
- Saskia Wildi
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Selina Nager
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Kevin Akeret
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Sena Özkaratufan
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Niklaus Krayenbühl
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
- Division of Pediatric Neurosurgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - Oliver Bozinov
- Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Luca Regli
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Julia Velz
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
- Division of Pediatric Neurosurgery, University Children's Hospital Zurich, Zurich, Switzerland
| |
Collapse
|
7
|
Thomson BR, Richter H, Akeret K, Buzzi RM, Anagnostakou V, van Niftrik CHB, Schwendinger N, Kulcsar Z, Kronen PW, Regli L, Fierstra J, Schaer DJ, Hugelshofer M. Blood oxygenation-level dependent cerebrovascular reactivity imaging as strategy to monitor CSF-hemoglobin toxicity. J Stroke Cerebrovasc Dis 2023; 32:106985. [PMID: 36640721 DOI: 10.1016/j.jstrokecerebrovasdis.2023.106985] [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: 10/27/2022] [Revised: 12/27/2022] [Accepted: 01/09/2023] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVES Cell-free hemoglobin in the cerebrospinal fluid (CSF-Hb) may be one of the main drivers of secondary brain injury after aneurysmal subarachnoid hemorrhage (aSAH). Haptoglobin scavenging of CSF-Hb has been shown to mitigate cerebrovascular disruption. Using digital subtraction angiography (DSA) and blood oxygenation-level dependent cerebrovascular reactivity imaging (BOLD-CVR) the aim was to assess the acute toxic effect of CSF-Hb on cerebral blood flow and autoregulation, as well as to test the protective effects of haptoglobin. METHODS DSA imaging was performed in eight anesthetized and ventilated sheep (mean weight: 80.4 kg) at baseline, 15, 30, 45 and 60 minutes after infusion of hemoglobin (Hb) or co-infusion with haptoglobin (Hb:Haptoglobin) into the left lateral ventricle. Additionally, 10 ventilated sheep (mean weight: 79.8 kg) underwent BOLD-CVR imaging to assess the cerebrovascular reserve capacity. RESULTS DSA imaging did not show a difference in mean transit time or cerebral blood flow. Whole-brain BOLD-CVR compared to baseline decreased more in the Hb group after 15 minutes (Hb vs Hb:Haptoglobin: -0.03 ± 0.01 vs -0.01 ± 0.02) and remained diminished compared to Hb:Haptoglobin group after 30 minutes (Hb vs Hb:Haptoglobin: -0.03 ± 0.01 vs 0.0 ± 0.01), 45 minutes (Hb vs Hb:Haptoglobin: -0.03 ± 0.01 vs 0.01 ± 0.02) and 60 minutes (Hb vs Hb:Haptoglobin: -0.03 ± 0.02 vs 0.01 ± 0.01). CONCLUSION It is demonstrated that CSF-Hb toxicity leads to rapid cerebrovascular reactivity impairment, which is blunted by haptoglobin co-infusion. BOLD-CVR may therefore be further evaluated as a monitoring strategy for CSF-Hb toxicity after aSAH.
Collapse
Affiliation(s)
- Bart R Thomson
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland; Division of Internal Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Henning Richter
- Clinic for Diagnostic Imaging, Department of Clinical Diagnostics and Services, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland; Center for Applied Biotechnology and Molecular Medicine (CABMM), University of Zurich, Zurich, Switzerland
| | - Kevin Akeret
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Raphael M Buzzi
- Division of Internal Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Vania Anagnostakou
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland; Department of Radiology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Christiaan H B van Niftrik
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Nina Schwendinger
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Zsolt Kulcsar
- Center for Applied Biotechnology and Molecular Medicine (CABMM), University of Zurich, Zurich, Switzerland; Department of Neuroradiology, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Peter W Kronen
- Center for Applied Biotechnology and Molecular Medicine (CABMM), University of Zurich, Zurich, Switzerland; Veterinary Anaesthesia Services - International, Winterthur, Switzerland
| | - Luca Regli
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Jorn Fierstra
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Dominik J Schaer
- Division of Internal Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Michael Hugelshofer
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland; Center for Applied Biotechnology and Molecular Medicine (CABMM), University of Zurich, Zurich, Switzerland.
| |
Collapse
|
8
|
Kernbach JM, Delev D, Neuloh G, Clusmann H, Bzdok D, Eickhoff SB, Staartjes VE, Vasella F, Weller M, Regli L, Serra C, Krayenbühl N, Akeret K. Meta-topologies define distinct anatomical classes of brain tumours linked to histology and survival. Brain Commun 2022; 5:fcac336. [PMID: 36632188 PMCID: PMC9830987 DOI: 10.1093/braincomms/fcac336] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 08/06/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022] Open
Abstract
The current World Health Organization classification integrates histological and molecular features of brain tumours. The aim of this study was to identify generalizable topological patterns with the potential to add an anatomical dimension to the classification of brain tumours. We applied non-negative matrix factorization as an unsupervised pattern discovery strategy to the fine-grained topographic tumour profiles of 936 patients with neuroepithelial tumours and brain metastases. From the anatomical features alone, this machine learning algorithm enabled the extraction of latent topological tumour patterns, termed meta-topologies. The optimal part-based representation was automatically determined in 10 000 split-half iterations. We further characterized each meta-topology's unique histopathologic profile and survival probability, thus linking important biological and clinical information to the underlying anatomical patterns. In neuroepithelial tumours, six meta-topologies were extracted, each detailing a transpallial pattern with distinct parenchymal and ventricular compositions. We identified one infratentorial, one allopallial, three neopallial (parieto-occipital, frontal, temporal) and one unisegmental meta-topology. Each meta-topology mapped to distinct histopathologic and molecular profiles. The unisegmental meta-topology showed the strongest anatomical-clinical link demonstrating a survival advantage in histologically identical tumours. Brain metastases separated to an infra- and supratentorial meta-topology with anatomical patterns highlighting their affinity to the cortico-subcortical boundary of arterial watershed areas.Using a novel data-driven approach, we identified generalizable topological patterns in both neuroepithelial tumours and brain metastases. Differences in the histopathologic profiles and prognosis of these anatomical tumour classes provide insights into the heterogeneity of tumour biology and might add to personalized clinical decision-making.
Collapse
Affiliation(s)
| | | | - Georg Neuloh
- Department of Neurosurgery, Faculty of Medicine, RWTH Aachen University, Pauwelsstrasse 30, 52074 Aachen, Germany,Center for Integrated Oncology, Düsseldorf (CIO ABCD), Universities Aachen, Bonn, Cologne, Germany
| | - Hans Clusmann
- Department of Neurosurgery, Faculty of Medicine, RWTH Aachen University, Pauwelsstrasse 30, 52074 Aachen, Germany,Center for Integrated Oncology, Düsseldorf (CIO ABCD), Universities Aachen, Bonn, Cologne, Germany
| | - Danilo Bzdok
- Department of Biomedical Engineering, McConnell Brain Imaging Centre, Montreal Neurological Institute, Faculty of Medicine, School of Computer Science, McGill University, 845 Sherbrooke St W, Montreal, Quebec H3A 0G4, Canada,Mila—Quebec Artificial Intelligence Institute, 6666 Rue Saint-Urbain, Montreal, Quebec H2S 3H1, Canada
| | - Simon B Eickhoff
- Institute of Neuroscience and Medicine (INM-7), Research Centre Jülich, Wilhelm Johnen Strasse, 52428 Jülich, Germany,Institute of Systems Neuroscience, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstrasse 5, 40225 Düsseldorf, Germany
| | - Victor E Staartjes
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland
| | - Flavio Vasella
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland
| | - Michael Weller
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland
| | - Carlo Serra
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland
| | - Niklaus Krayenbühl
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland,Division of Pediatric Neurosurgery, University Children's Hospital, Steinwiesstrasse 75, 8032 Zurich, Switzerland
| | - Kevin Akeret
- Correspondence to: Kevin Akeret, MD PhD Department of Neurosurgery, Clinical Neuroscience Center University Hospital Zurich and University of Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland E-mail:
| |
Collapse
|
9
|
Akeret K, Buzzi RM, Thomson BR, Schwendinger N, Klohs J, Schulthess-Lutz N, Baselgia L, Hansen K, Regli L, Vallelian F, Hugelshofer M, Schaer DJ. MyD88-TLR4-dependent choroid plexus activation precedes perilesional inflammation and secondary brain edema in a mouse model of intracerebral hemorrhage. J Neuroinflammation 2022; 19:290. [PMID: 36482445 PMCID: PMC9730653 DOI: 10.1186/s12974-022-02641-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 11/10/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The functional neurological outcome of patients with intracerebral hemorrhage (ICH) strongly relates to the degree of secondary brain injury (ICH-SBI) evolving within days after the initial bleeding. Different mechanisms including the incitement of inflammatory pathways, dysfunction of the blood-brain barrier (BBB), activation of resident microglia, and an influx of blood-borne immune cells, have been hypothesized to contribute to ICH-SBI. Yet, the spatiotemporal interplay of specific inflammatory processes within different brain compartments has not been sufficiently characterized, limiting potential therapeutic interventions to prevent and treat ICH-SBI. METHODS We used a whole-blood injection model in mice, to systematically characterized the spatial and temporal dynamics of inflammatory processes after ICH using 7-Tesla magnetic resonance imaging (MRI), spatial RNA sequencing (spRNAseq), functional BBB assessment, and immunofluorescence average-intensity-mapping. RESULTS We identified a pronounced early response of the choroid plexus (CP) peaking at 12-24 h that was characterized by inflammatory cytokine expression, epithelial and endothelial expression of leukocyte adhesion molecules, and the accumulation of leukocytes. In contrast, we observed a delayed secondary reaction pattern at the injection site (striatum) peaking at 96 h, defined by gene expression corresponding to perilesional leukocyte infiltration and correlating to the delayed signal alteration seen on MRI. Pathway analysis revealed a dependence of the early inflammatory reaction in the CP on toll-like receptor 4 (TLR4) signaling via myeloid differentiation factor 88 (MyD88). TLR4 and MyD88 knockout mice corroborated this observation, lacking the early upregulation of adhesion molecules and leukocyte infiltration within the CP 24 h after whole-blood injection. CONCLUSIONS We report a biphasic brain reaction pattern after ICH with a MyD88-TLR4-dependent early inflammatory response of the CP, preceding inflammation, edema and leukocyte infiltration at the lesion site. Pharmacological targeting of the early CP activation might harbor the potential to modulate the development of ICH-SBI.
Collapse
Affiliation(s)
- Kevin Akeret
- grid.7400.30000 0004 1937 0650Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital and University of Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland
| | - Raphael M. Buzzi
- grid.7400.30000 0004 1937 0650Division of Internal Medicine, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Bart R. Thomson
- grid.7400.30000 0004 1937 0650Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital and University of Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland ,grid.7400.30000 0004 1937 0650Division of Internal Medicine, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Nina Schwendinger
- grid.7400.30000 0004 1937 0650Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital and University of Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland ,grid.7400.30000 0004 1937 0650Division of Internal Medicine, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Jan Klohs
- grid.7400.30000 0004 1937 0650Institute for Biomedical Engineering, University of Zurich and ETH Zurich, Zurich, Switzerland
| | - Nadja Schulthess-Lutz
- grid.7400.30000 0004 1937 0650Division of Internal Medicine, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Livio Baselgia
- grid.7400.30000 0004 1937 0650Division of Internal Medicine, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Kerstin Hansen
- grid.7400.30000 0004 1937 0650Division of Internal Medicine, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Luca Regli
- grid.7400.30000 0004 1937 0650Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital and University of Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland
| | - Florence Vallelian
- grid.7400.30000 0004 1937 0650Division of Internal Medicine, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Michael Hugelshofer
- grid.7400.30000 0004 1937 0650Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital and University of Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland
| | - Dominik J. Schaer
- grid.7400.30000 0004 1937 0650Division of Internal Medicine, Universitätsspital and University of Zurich, Zurich, Switzerland
| |
Collapse
|
10
|
Wolpert F, Grossenbacher B, Moors S, Lareida A, Serra C, Akeret K, Roth P, Imbach L, Le Rhun E, Regli L, Weller M, Galovic M. Postoperative progression of brain metastasis is associated with seizures. Epilepsia 2022; 63:e138-e143. [PMID: 35892318 DOI: 10.1111/epi.17379] [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: 01/22/2022] [Revised: 07/23/2022] [Accepted: 07/25/2022] [Indexed: 01/07/2023]
Abstract
Seizures in patients with brain metastases have an impact on morbidity and quality of life. The influence of tumor growth on the risk of seizures in these patients is not well defined. In this cohort study, we evaluated adult patients from the University Hospital of Zurich following resection of brain metastases from solid tumors, with or without preoperative seizures, at 3, 6, 9, and 12 months postoperatively. Brain magnetic resonance imaging was assessed for tumor progression using the Response Assessment in Neuro-Oncology criteria. The quarterly risk of unprovoked seizures was modeled with mixed effects logistic regression. We analyzed 444 time frames in 220 patients. Progression of brain metastases was independently associated with seizures during the respective quarterly follow-up period (odds ratio = 3.9, 95% confidence interval = 1.3-11.3, p = .014). Complete resection of brain metastases was associated with a lower risk of seizures (odds ratio = .2, 95% confidence interval = .04-.7, p = .015). Postoperative progression of brain metastases quadrupled the risk of seizures; therefore, vigorous follow-up may be useful to identify tumor progression and gauge the risk of seizures. The identification of patients at high seizure risk may have implications for treatment decisions and influence aspects of daily life. Breakthrough seizures may indicate brain metastases progression.
Collapse
Affiliation(s)
- Fabian Wolpert
- Department of Neurology, Clinical Neuroscience Center and Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Bettina Grossenbacher
- Department of Neurology, Clinical Neuroscience Center and Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Selina Moors
- Department of Neurology, Clinical Neuroscience Center and Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Anna Lareida
- Department of Neurology, Clinical Neuroscience Center and Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Carlo Serra
- Department of Neurology, Clinical Neuroscience Center and Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Kevin Akeret
- Department of Neurosurgery, Clinical Neuroscience Center and Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Patrick Roth
- Department of Neurology, Clinical Neuroscience Center and Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Lukas Imbach
- Department of Neurology, Clinical Neuroscience Center and Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Emilie Le Rhun
- Department of Neurology, Clinical Neuroscience Center and Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland.,Department of Neurosurgery, Clinical Neuroscience Center and Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, Clinical Neuroscience Center and Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Michael Weller
- Department of Neurology, Clinical Neuroscience Center and Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Marian Galovic
- Department of Neurology, Clinical Neuroscience Center and Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
| |
Collapse
|
11
|
Bücker P, Buzzi RM, Akeret K, Mosberger L, Richter H, Sperling M, Hugelshofer M, Schaer DJ, Karst U. A model to visualize the fate of iron after intracranial hemorrhage using isotopic tracers and elemental bioimaging. Metallomics 2022; 14:6652217. [PMID: 35906878 DOI: 10.1093/mtomcs/mfac057] [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] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 07/15/2022] [Indexed: 11/13/2022]
Abstract
Hemoglobin-iron is a red-blood-cell toxin contributing to secondary brain injury after intracranial bleeding. We present a model to visualize an intracerebral hematoma and secondary hemoglobin-iron distribution by detecting 58Fe-labeled hemoglobin (Hb) with laser ablation-inductively coupled plasma-mass spectrometry on mouse brain cryosections after stereotactic whole blood injection for different time periods. The generation of 58Fe-enriched blood and decisive steps in the acute hemorrhage formation and evolution was evaluated. The model allows to visualize and quantify 58Fe with high spatial resolution and striking signal-to-noise ratio. Script-based evaluation of the delocalization-depth revealed ongoing 58Fe delocalization in the brain even six days after hematoma induction. Collectively, the model can quantify the distribution of Hb-derived iron post-bleeding, providing a methodological framework to study the pathophysiological basis of cell-free Hb toxicity in hemorrhagic stroke.
Collapse
Affiliation(s)
- Patrick Bücker
- Institute of Inorganic and Analytical Chemistry, University of Münster, Münster, Germany
| | - Raphael M Buzzi
- Division of Internal Medicine, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Kevin Akeret
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Leila Mosberger
- Division of Internal Medicine, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Henning Richter
- Diagnostic Imaging Research Unit, Clinic for Diagnostic Imaging, University of Zurich, Zurich, Switzerland
| | - Michael Sperling
- Institute of Inorganic and Analytical Chemistry, University of Münster, Münster, Germany
| | - Michael Hugelshofer
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Dominik J Schaer
- Division of Internal Medicine, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Uwe Karst
- Institute of Inorganic and Analytical Chemistry, University of Münster, Münster, Germany
| |
Collapse
|
12
|
Akeret K, Forkel SJ, Buzzi RM, Vasella F, Amrein I, Colacicco G, Serra C, Krayenbühl N. Multimodal anatomy of the human forniceal commissure. Commun Biol 2022; 5:742. [PMID: 35879431 PMCID: PMC9314404 DOI: 10.1038/s42003-022-03692-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 07/07/2022] [Indexed: 11/25/2022] Open
Abstract
Ambiguity surrounds the existence and morphology of the human forniceal commissure. We combine advanced in-vivo tractography, multidirectional ex-vivo fiber dissection, and multiplanar histological analysis to characterize this structure’s anatomy. Across all 178 subjects, in-vivo fiber dissection based on the Human Connectome Project 7 T MRI data identifies no interhemispheric connections between the crura fornicis. Multidirectional ex-vivo fiber dissection under the operating microscope demonstrates the psalterium as a thin soft-tissue membrane spanning between the right and left crus fornicis, but exposes no commissural fibers. Multiplanar histological analysis with myelin and Bielchowsky silver staining, however, visualizes delicate cruciform fibers extending between the crura fornicis, enclosed by connective tissue, the psalterium. The human forniceal commissure is therefore much more delicate than previously described and presented in anatomical textbooks. This finding is consistent with the observed phylogenetic trend of a reduction of the forniceal commissure in non-human primates compared to non-primate eutherian mammals. Anatomical dissection and tractography elucidate the delicate nature of the human forniceal commissure, an interhemispheric white matter circuit.
Collapse
Affiliation(s)
- Kevin Akeret
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Stephanie J Forkel
- Brain Connectivity and Behaviour Laboratory, Sorbonne Universities, Paris, France.,Donders Centre for Cognition, Radboud University, Thomas van Aquinostraat 4, 6525 GD, Nijmegen, the Netherlands.,Centre for Neuroimaging Sciences, Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,Departments of Neurosurgery, Technical University of Munich School of Medicine, Munich, Germany
| | - Raphael M Buzzi
- Division of Internal Medicine, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Flavio Vasella
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Irmgard Amrein
- Institute of Anatomy, University of Zurich, Zurich, Switzerland.,Department of Health Sciences and Technology, ETH, Zurich, Switzerland
| | | | - Carlo Serra
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Niklaus Krayenbühl
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland. .,Division of Pediatric Neurosurgery, University Children's Hospital, Zurich, Switzerland.
| |
Collapse
|
13
|
Akeret K, Buzzi RM, Saxenhofer M, Bieri K, Chiavi D, Thomson BR, Grüttner-Durmaz M, Schwendinger N, Humar R, Regli L, van Doormaal TPC, Held U, Keller E, Hugelshofer M, Schaer DJ. The HeMoVal study protocol: a prospective international multicenter cohort study to validate cerebrospinal fluid hemoglobin as a monitoring biomarker for aneurysmal subarachnoid hemorrhage related secondary brain injury. BMC Neurol 2022; 22:267. [PMID: 35850705 PMCID: PMC9290286 DOI: 10.1186/s12883-022-02789-w] [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: 11/22/2021] [Accepted: 07/07/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction Preclinical studies provided a strong rationale for a pathophysiological link between cell-free hemoglobin in the cerebrospinal fluid (CSF-Hb) and secondary brain injury after subarachnoid hemorrhage (SAH-SBI). In a single-center prospective observational clinical study, external ventricular drain (EVD) based CSF-Hb proved to be a promising biomarker to monitor for SAH-SBI. The primary objective of the HeMoVal study is to prospectively validate the association between EVD based CSF-Hb and SAH-SBI during the first 14 days post-SAH. Secondary objectives include the assessment of the discrimination ability of EVD based CSF-Hb for SAH-SBI and the definition of a clinically relevant range of EVD based CSF-Hb toxicity. In addition, lumbar drain (LD) based CSF-Hb will be assessed for its association with and discrimination ability for SAH-SBI. Methods HeMoVal is a prospective international multicenter observational cohort study. Adult patients admitted with aneurysmal subarachnoid hemorrhage (aSAH) are eligible. While all patients with aSAH are included, we target a sample size of 250 patients with EVD within the first 14 day after aSAH. Epidemiologic and disease-specific baseline measures are assessed at the time of study inclusion. In patients with EVD or LD, each day during the first 14 days post-SAH, 2 ml of CSF will be sampled in the morning, followed by assessment of the patients for SAH-SBI, co-interventions, and complications in the afternoon. After 3 months, a clinical follow-up will be performed. For statistical analysis, the cohort will be stratified into an EVD, LD and full cohort. The primary analysis will quantify the strength of association between EVD based CSF-Hb and SAH-SBI in the EVD cohort based on a generalized additive model. Secondary analyses include the strength of association between LD based CSF-Hb and SAH-SBI in the LD cohort based on a generalized additive model, as well as the discrimination ability of CSF-Hb for SAH-SBI based on receiver operating characteristic (ROC) analyses. Discussion We hypothesize that this study will validate the value of CSF-Hb as a biomarker to monitor for SAH-SBI. In addition, the results of this study will provide the potential base to define an intervention threshold for future studies targeting CSF-Hb toxicity after aSAH. Study registration ClinicalTrials.gov Identifier NCT04998370. Date of registration: August 10, 2021.
Collapse
Affiliation(s)
- Kevin Akeret
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Raphael M Buzzi
- Division of Internal Medicine, Universitätsspital and University of Zurich, Zurich, Switzerland
| | | | | | - Deborah Chiavi
- Department of Biostatistics at Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Bart R Thomson
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Manuela Grüttner-Durmaz
- Clinical Trials Center - Research Ward (CTC-RW), University Hospital Zurich, Zurich, Switzerland
| | - Nina Schwendinger
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Rok Humar
- Division of Internal Medicine, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Tristan P C van Doormaal
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital and University of Zurich, Zurich, Switzerland.,Department of Neurology and Neurosurgery, University Medical Center, Utrecht, The Netherlands
| | - Ulrike Held
- Department of Biostatistics at Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Emanuela Keller
- Neurointensive Care Unit, Department of Neurosurgery and Institute of Intensive Care Medicine, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Michael Hugelshofer
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital and University of Zurich, Zurich, Switzerland.
| | - Dominik J Schaer
- Division of Internal Medicine, Universitätsspital and University of Zurich, Zurich, Switzerland
| | | |
Collapse
|
14
|
Velz J, Özkaratufan S, Krayenbühl N, Beccaria K, Akeret K, Attieh C, Ghannam B, Guida L, Benichi S, Bozinov O, Puget S, Blauwblomme T, Regli L. Pediatric brainstem cavernous malformations: 2-center experience in 40 children. J Neurosurg Pediatr 2022; 29:612-623. [PMID: 35303707 DOI: 10.3171/2022.1.peds21538] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/13/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Brainstem cavernous malformations (BSCMs) are relatively uncommon, low-flow vascular lesions in children. Given the paucity of data, guidelines regarding the clinical management of BSCMs in children are lacking and the surgical indication is most commonly based on an individual surgeon's judgment and experience. The goal in this study was to evaluate the clinical behavior of BSCMs in childhood and the long-term outcome in children managed conservatively and surgically. METHODS This was an observational, retrospective study including all children with BSCMs who were followed at 2 institutions between 2008 and 2020. RESULTS The study population consisted of 40 children (27 boys, 67.5%) with a mean age of 11.4 years. Twenty-three children (57.5%) were managed conservatively, whereas 17 children (42.5%) underwent resection of BSCMs. An aggressive clinical course was observed in 13 children (32.5%), who experienced multiple hemorrhages with a progressive pattern of neurological decline. Multiple BSCMs were observed in 8 patients, of whom 3 patients presented with a complex of multiple tightly attached BSCMs and posed a significant therapeutic challenge. The overall long-term outcome was favorable (modified Rankin Scale [mRS] scores 0-2) in 36 patients (90%), whereas an unfavorable outcome (mRS scores 3 and 4) was seen in 4 children (10%). An mRS score of 5 or 6 was not observed. The mean (± SD) follow-up was 88.0 (± 92.6) months. CONCLUSIONS The clinical course of BSCMs in children is highly variable, with benign lesions on the one hand and highly aggressive lesions with repetitive hemorrhages on the other. Given the greater life expectancy and the known higher functional recovery in children, surgical treatment should be considered early in young patients presenting with surgically accessible lesions and an aggressive clinical course, and it should be performed in a high-volume center.
Collapse
Affiliation(s)
- Julia Velz
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Switzerland
- 2University of Zurich, Switzerland
- 3Division of Pediatric Neurosurgery, University Children's Hospital Zurich, Switzerland
- 4Department of Pediatric Neurosurgery, APHP, Hôpital Necker, Paris, France
| | - Sena Özkaratufan
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Switzerland
- 2University of Zurich, Switzerland
| | - Niklaus Krayenbühl
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Switzerland
- 2University of Zurich, Switzerland
- 3Division of Pediatric Neurosurgery, University Children's Hospital Zurich, Switzerland
| | - Kevin Beccaria
- 4Department of Pediatric Neurosurgery, APHP, Hôpital Necker, Paris, France
- 5Université de Paris, France
| | - Kevin Akeret
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Switzerland
- 2University of Zurich, Switzerland
| | - Christian Attieh
- 4Department of Pediatric Neurosurgery, APHP, Hôpital Necker, Paris, France
| | - Boulos Ghannam
- 4Department of Pediatric Neurosurgery, APHP, Hôpital Necker, Paris, France
| | - Lelio Guida
- 4Department of Pediatric Neurosurgery, APHP, Hôpital Necker, Paris, France
- 5Université de Paris, France
| | - Sandro Benichi
- 4Department of Pediatric Neurosurgery, APHP, Hôpital Necker, Paris, France
- 5Université de Paris, France
| | - Oliver Bozinov
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Switzerland
- 6Department of Neurosurgery, Kantonsspital St. Gallen, Switzerland; and
| | - Stephanie Puget
- 4Department of Pediatric Neurosurgery, APHP, Hôpital Necker, Paris, France
- 7Department of Neurosurgery, Hôpital Pierre Zobda Quitman, CHU de Fort de France, Université des Antilles, Fort de France, Martinique
| | - Thomas Blauwblomme
- 4Department of Pediatric Neurosurgery, APHP, Hôpital Necker, Paris, France
- 5Université de Paris, France
| | - Luca Regli
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Switzerland
- 2University of Zurich, Switzerland
| |
Collapse
|
15
|
Akeret K, Hugelshofer M, Schaer DJ, Buzzi RM. Spatial transcriptome data from coronal mouse brain sections after striatal injection of heme and heme-hemopexin. Data Brief 2022; 41:107866. [PMID: 35141374 PMCID: PMC8814302 DOI: 10.1016/j.dib.2022.107866] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 01/04/2022] [Accepted: 01/19/2022] [Indexed: 12/04/2022] Open
Abstract
Hemorrhagic stroke is a major cause of morbidity and mortality worldwide. Secondary mechanisms of brain injury adversely affect functional outcome in patients after intracranial hemorrhage. Potential drivers of intracranial hemorrhage-related secondary brain injury are hemoglobin and its downstream degradation products released from lysed red blood cells, such as free heme. We established a mouse model with stereotactic striatal injection of heme-albumin to gain insights into the toxicity mechanisms of free heme in the brain and assess the therapeutic potential of heme binding and biochemical neutralization by hemopexin. We defined the dose-dependent transcriptional effect of heme or heme-hemopexin exposure 24 h after injection by spatial transcriptome analysis of lesion-centered coronal cryosections. The spatial transcriptome was interpreted in a multimodal approach along with histology, magnetic resonance imaging, and behavioral data and reported in the associated research article “Spatial transcriptome analysis defines heme as a hemopexin-targetable inflammatoxin in the brain” [1]. The spatially resolved transcriptome dataset made available here is intended for continued analysis of free heme toxicity in the brain, which is of potential pathophysiological and therapeutic significance in the context of a wide range of neurovascular and neurodegenerative diseases.
Collapse
|
16
|
Buzzi RM, Akeret K, Schwendinger N, Klohs J, Vallelian F, Hugelshofer M, Schaer DJ. Spatial transcriptome analysis defines heme as a hemopexin-targetable inflammatoxin in the brain. Free Radic Biol Med 2022; 179:277-287. [PMID: 34793930 DOI: 10.1016/j.freeradbiomed.2021.11.011] [Citation(s) in RCA: 2] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/06/2021] [Accepted: 11/09/2021] [Indexed: 01/18/2023]
Abstract
After intracranial hemorrhage, heme is released from cell-free hemoglobin. This red blood cell component may drive secondary brain injury at the hematoma‒brain interface. This study aimed to generate a spatially resolved map of transcriptome-wide gene expression changes in the heme-exposed brain and to define the potential therapeutic activity of the heme-binding protein, hemopexin. We stereotactically injected saline, heme, or heme‒hemopexin into the striatum of C57BL/6J mice. After 24 h, we elucidated the two-dimensional spatial transcriptome by sequencing 21760 tissue-covered features, at a mean transcript coverage of 3849 genes per feature. In parallel, we studied the extravasation of systemically administered fluorescein isothiocyanate labeled (FITC)-dextran, magnetic resonance imaging features indicative of focal edema and perfusion, and neurological functions as translational correlates of heme toxicity. We defined a cerebral heme-response signature by performing bidimensional differential gene expression analysis, based on unsupervised clustering and manual segmentation of sequenced features. Heme exerted a consistent and dose-dependent proinflammatory activity in the brain, which occurred at minimal exposures, below the toxicity threshold for the induction of vascular leakage. We found dose-dependent regional divergence of proinflammatory heme signaling pathways, consistent with reactive astrocytosis and microglial activation. Co-injection of heme with hemopexin attenuated heme-induced gene expression changes and preserved the homeostatic microglia signature. Hemopexin also prevented heme-induced disruption of the blood‒brain barrier and radiological and functional signals of heme injury in the brain. In conclusion, we defined heme as a potent inflammatoxin that may drive secondary brain injury after intracerebral hemorrhage. Co-administration of hemopexin attenuated the heme-derived toxic effects on a molecular, cellular, and functional level, suggesting a translational therapeutic strategy.
Collapse
Affiliation(s)
- Raphael M Buzzi
- Division of Internal Medicine, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Kevin Akeret
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital und University of Zurich; Zurich, Switzerland
| | - Nina Schwendinger
- Division of Internal Medicine, Universitätsspital and University of Zurich, Zurich, Switzerland; Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital und University of Zurich; Zurich, Switzerland
| | - Jan Klohs
- Institute for Biomedical Engineering, University of Zurich and ETH Zurich, Zurich, Switzerland
| | - Florence Vallelian
- Division of Internal Medicine, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Michael Hugelshofer
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital und University of Zurich; Zurich, Switzerland
| | - Dominik J Schaer
- Division of Internal Medicine, Universitätsspital and University of Zurich, Zurich, Switzerland.
| |
Collapse
|
17
|
Akeret K, Buzzi RM, Schaer CA, Thomson BR, Vallelian F, Wang S, Willms J, Sebök M, Held U, Deuel JW, Humar R, Regli L, Keller E, Hugelshofer M, Schaer DJ. Cerebrospinal fluid hemoglobin drives subarachnoid hemorrhage-related secondary brain injury. J Cereb Blood Flow Metab 2021; 41:3000-3015. [PMID: 34102922 PMCID: PMC8545037 DOI: 10.1177/0271678x211020629] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Secondary brain injury after aneurysmal subarachnoid hemorrhage (SAH-SBI) contributes to poor outcomes in patients after rupture of an intracranial aneurysm. The lack of diagnostic biomarkers and novel drug targets represent an unmet need. The aim of this study was to investigate the clinical and pathophysiological association between cerebrospinal fluid hemoglobin (CSF-Hb) and SAH-SBI. In a cohort of 47 patients, we collected daily CSF-samples within 14 days after aneurysm rupture. There was very strong evidence for a positive association between spectrophotometrically determined CSF-Hb and SAH-SBI. The accuracy of CSF-Hb to monitor for SAH-SBI markedly exceeded that of established methods (AUC: 0.89 [0.85-0.92]). Temporal proteome analysis revealed erythrolysis accompanied by an adaptive macrophage response as the two dominant biological processes in the CSF-space after aneurysm rupture. Ex-vivo experiments on the vasoconstrictive and oxidative potential of Hb revealed critical inflection points overlapping CSF-Hb thresholds in patients with SAH-SBI. Selective depletion and in-solution neutralization by haptoglobin or hemopexin efficiently attenuated the vasoconstrictive and lipid peroxidation activities of CSF-Hb. Collectively, the clinical association between high CSF-Hb levels and SAH-SBI, the underlying pathophysiological rationale, and the favorable effects of haptoglobin and hemopexin in ex-vivo experiments position CSF-Hb as a highly attractive biomarker and potential drug target.
Collapse
Affiliation(s)
- Kevin Akeret
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital und University of Zurich; Zurich, Switzerland
| | - Raphael M Buzzi
- Division of Internal Medicine, Universitätsspital and University of Zurich; Zurich, Switzerland
| | - Christian A Schaer
- Department of Anesthesiology, Universitätsspital and University of Zurich; Zurich, Switzerland
| | - Bart R Thomson
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital und University of Zurich; Zurich, Switzerland
| | - Florence Vallelian
- Division of Internal Medicine, Universitätsspital and University of Zurich; Zurich, Switzerland
| | - Sophie Wang
- Neurointensive Care Unit, Department of Neurosurgery and Institute of Intensive Care Medicine, Universitätsspital and University of Zurich; Zurich, Switzerland
| | - Jan Willms
- Neurointensive Care Unit, Department of Neurosurgery and Institute of Intensive Care Medicine, Universitätsspital and University of Zurich; Zurich, Switzerland
| | - Martina Sebök
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital und University of Zurich; Zurich, Switzerland
| | - Ulrike Held
- Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics, University of Zurich; Zurich, Switzerland
| | - Jeremy W Deuel
- Division of Internal Medicine, Universitätsspital and University of Zurich; Zurich, Switzerland
| | - Rok Humar
- Division of Internal Medicine, Universitätsspital and University of Zurich; Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital und University of Zurich; Zurich, Switzerland
| | - Emanuela Keller
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital und University of Zurich; Zurich, Switzerland.,Neurointensive Care Unit, Department of Neurosurgery and Institute of Intensive Care Medicine, Universitätsspital and University of Zurich; Zurich, Switzerland
| | - Michael Hugelshofer
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital und University of Zurich; Zurich, Switzerland
| | - Dominik J Schaer
- Division of Internal Medicine, Universitätsspital and University of Zurich; Zurich, Switzerland
| |
Collapse
|
18
|
Jenkins FS, Vasella F, Padevit L, Mutschler V, Akeret K, Velz J, Regli L, Sarnthein J, Neidert MC. Preoperative risk factors associated with new focal neurological deficit and other major adverse events in first-time intracranial meningioma neurosurgery. Acta Neurochir (Wien) 2021; 163:2871-2879. [PMID: 34259901 PMCID: PMC8437836 DOI: 10.1007/s00701-021-04897-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 05/26/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Neurosurgical resection is the mainstay of meningioma treatment. Adverse event (AE) rates of meningioma resections are significant, but preoperative risk factors for major AEs in patients undergoing first-time meningioma surgery are largely unknown. The aim of this study was to explore major AEs and identify preoperative risk factors in patients undergoing first-time meningioma surgery. METHODS Data on all meningioma resections performed at the University Hospital Zurich from 1 January 2013 to 31 December 2018 were collected in a prospective registry. All AEs that occurred within 3 months of surgery were documented in detail and classified as "minor" or "major." Statistical analysis included initial individual bivariate analyses of all preoperative factors and the occurrence of major AEs. Statistically significant variables were then included in a logistic regression model to identify predictors. RESULTS Three hundred forty-five patients were included in the study. Mean age was 58.1 years, and 77.1% of patients were female. The overall major AE rate was 20.6%; the most common of which was a new focal neurological deficit (12.8% of patients). Six preoperative factors showed a significant association with the occurrence of major AEs in bivariate analysis. All variables included in the logistic regression model showed increased odds of occurrence of major AE, but only tumor complexity as measured by the Milan Complexity Scale was a statistically significant predictor, with a score of 4 or more having twice the odds of major AEs (OR: 2.00, 95% CI: 1.15-3.48). CONCLUSION High tumor complexity is an independent predictor of the occurrence of major AEs following meningioma resection. Preoperative assessment of tumor complexity using the Milan Complexity Scale is warranted and can aid communication with patients about AE rates and surgical decision-making.
Collapse
|
19
|
Akeret K, Vasella F, Staartjes VE, Velz J, Müller T, Neidert MC, Weller M, Regli L, Serra C, Krayenbühl N. Anatomical phenotyping and staging of brain tumours. Brain 2021; 145:1162-1176. [PMID: 34554211 DOI: 10.1093/brain/awab352] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 03/14/2021] [Revised: 07/25/2021] [Accepted: 08/21/2021] [Indexed: 11/14/2022] Open
Abstract
Unlike other tumors, the anatomical extent of brain tumors is not objectified and quantified through staging. Staging systems are based on understanding the anatomical sequence of tumor progression and its relationship to histopathological dedifferentiation and survival. The aim of this study was to describe the spatiotemporal phenotype of the most frequent brain tumor entities, to assess the association of anatomical tumor features with survival probability and to develop a staging system for WHO grade 2 and 3 gliomas and glioblastoma. Anatomical phenotyping was performed on a consecutive cohort of 1000 patients with first diagnosis of a primary or secondary brain tumor. Tumor probability in different topographic, phylogenetic and ontogenetic parcellation units was assessed on preoperative MRI through normalization of the relative tumor prevalence to the relative volume of the respective structure. We analyzed the spatiotemporal tumor dynamics by cross-referencing preoperative against preceding and subsequent MRIs of the respective patient. The association between anatomical phenotype and outcome defined prognostically critical anatomical tumor features at diagnosis. Based on a hypothesized sequence of anatomical tumor progression, we developed a three-level staging system for WHO grade 2 and 3 gliomas and glioblastoma. This staging system was validated internally in the original cohort and externally in an independent cohort of 300 consecutive patients. While primary central nervous system lymphoma showed highest probability along white matter tracts, metastases enriched along terminal arterial flow areas. Neuroepithelial tumors mapped along all sectors of the ventriculocortical axis, while adjacent units were spared, consistent with a transpallial behavior within phylo-ontogenetic radial units. Their topographic pattern correlated with morphogenetic processes of convergence and divergence of radial units during phylo- and ontogenesis. While a ventriculofugal growth dominated in neuroepithelial tumors, a gradual deviation from this neuroepithelial spatiotemporal behavior was found with progressive histopathological dedifferentiation. The proposed three-level staging system for WHO grade 2 and 3 gliomas and glioblastoma correlated with the degree of histological dedifferentiation and proved accurate in terms of survival upon both internal and external validation. In conclusion, this study identified specific spatiotemporal phenotypes in brain tumors through topographic probability and growth pattern assessment. The association of anatomical tumor features with survival defined critical steps in the anatomical sequence of neuroepithelial tumor progression, based on which a staging system for WHO grade 2 and 3 gliomas and glioblastoma was developed and validated.
Collapse
Affiliation(s)
- Kevin Akeret
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, 8091 Zurich, Switzerland
| | - Flavio Vasella
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, 8091 Zurich, Switzerland.,Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, 8091 Zurich, Switzerland
| | - Victor E Staartjes
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, 8091 Zurich, Switzerland
| | - Julia Velz
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, 8091 Zurich, Switzerland
| | - Timothy Müller
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, 8091 Zurich, Switzerland
| | - Marian Christoph Neidert
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, 8091 Zurich, Switzerland
| | - Michael Weller
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, 8091 Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, 8091 Zurich, Switzerland
| | - Carlo Serra
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, 8091 Zurich, Switzerland
| | - Niklaus Krayenbühl
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, 8091 Zurich, Switzerland.,Division of Pediatric Neurosurgery, University Children's Hospital, 8032 Zurich, Switzerland
| |
Collapse
|
20
|
Buzzi RM, Owczarek CM, Akeret K, Tester A, Pereira N, Butcher R, Brügger-Verdon V, Hardy MP, Illi M, Wassmer A, Vallelian F, Humar R, Hugelshofer M, Buehler PW, Gentinetta T, Schaer DJ. Modular Platform for the Development of Recombinant Hemoglobin Scavenger Biotherapeutics. Mol Pharm 2021; 18:3158-3170. [PMID: 34292741 DOI: 10.1021/acs.molpharmaceut.1c00433] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 11/28/2022]
Abstract
Cell-free hemoglobin (Hb) is a driver of disease progression in conditions with intravascular or localized hemolysis. Genetic and acquired anemias or emergency medical conditions such as aneurysmal subarachnoid hemorrhage involve tissue Hb exposure. Haptoglobin (Hp) captures Hb in an irreversible protein complex and prevents its pathophysiological contributions to vascular nitric oxide depletion and tissue oxidation. Preclinical proof-of-concept studies suggest that human plasma-derived Hp is a promising therapeutic candidate for several Hb-driven diseases. Optimizing the efficacy and safety of Hb-targeting biotherapeutics may require structural and functional modifications for specific indications. Improved Hp variants could be designed to achieve the desired tissue distribution, metabolism, and elimination to target hemolytic disease states effectively. However, it is critical to ensure that these modifications maintain the function of Hp. Using transient mammalian gene expression of Hp combined with co-transfection of the pro-haptoglobin processing protease C1r-LP, we established a platform for generating recombinant Hp-variants. We designed an Hpβ-scaffold, which was expressed in this system at high levels as a monomeric unit (mini-Hp) while maintaining the key protective functions of Hp. We then used this Hpβ-scaffold as the basis to develop an initial proof-of-concept Hp fusion protein using human serum albumin as the fusion partner. Next, a hemopexin-Hp fusion protein with bispecific heme and Hb detoxification capacity was generated. Further, we developed a Hb scavenger devoid of CD163 scavenger receptor binding. The functions of these proteins were then characterized for Hb and heme-binding, binding of the Hp-Hb complexes with the clearance receptor CD163, antioxidant properties, and vascular nitric oxide sparing capacity. Our platform is designed to support the generation of innovative Hb scavenger biotherapeutics with novel modes of action and potentially improved formulation characteristics, function, and pharmacokinetics.
Collapse
Affiliation(s)
- Raphael M Buzzi
- Division of Internal Medicine, Universitätsspital and University of Zurich, Zurich 8091, Switzerland
| | | | - Kevin Akeret
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital und University of Zurich, Zurich 8091, Switzerland
| | - Andrea Tester
- CSL Limited, Bio21 Institute, Parkville, Victoria 3010, Australia
| | - Natasha Pereira
- CSL Limited, Bio21 Institute, Parkville, Victoria 3010, Australia
| | - Rebecca Butcher
- CSL Limited, Bio21 Institute, Parkville, Victoria 3010, Australia
| | | | - Matthew P Hardy
- CSL Limited, Bio21 Institute, Parkville, Victoria 3010, Australia
| | - Marlies Illi
- Research and Development, CSL Behring AG, Bern 3014, Switzerland
| | - Andreas Wassmer
- Research and Development, CSL Behring AG, Bern 3014, Switzerland
| | - Florence Vallelian
- Division of Internal Medicine, Universitätsspital and University of Zurich, Zurich 8091, Switzerland
| | - Rok Humar
- Division of Internal Medicine, Universitätsspital and University of Zurich, Zurich 8091, Switzerland
| | - Michael Hugelshofer
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital und University of Zurich, Zurich 8091, Switzerland
| | - Paul W Buehler
- Department of Pathology, The University of Maryland School of Medicine, Baltimore, Maryland 21201, United States.,The Center for Blood Oxygen Transport and Hemostasis, Department of Pediatrics, The University of Maryland School of Medicine, Baltimore, Maryland 21201, United States
| | | | - Dominik J Schaer
- Division of Internal Medicine, Universitätsspital and University of Zurich, Zurich 8091, Switzerland
| |
Collapse
|
21
|
Velz J, Neidert MC, Yang Y, Akeret K, Nakaji P, Regli L, Bozinov O. Mortality in Patients with Brainstem Cavernous Malformations. Cerebrovasc Dis 2021; 50:574-580. [PMID: 34134124 DOI: 10.1159/000516909] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 02/18/2021] [Accepted: 04/09/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Brainstem cavernous malformations (BSCM)-associated mortality has been reported up to 20% in patients managed conservatively, whereas postoperative mortality rates range from 0 to 1.9%. Our aim was to analyze the actual risk and causes of BSCM-associated mortality in patients managed conservatively and surgically based on our own patient cohort and a systematic literature review. METHODS Observational, retrospective single-center study encompassing all patients with BSCM that presented to our institution between 2006 and 2018. In addition, a systematic review was performed on all studies encompassing patients with BSCM managed conservatively and surgically. RESULTS Of 118 patients, 54 were treated conservatively (961.0 person years follow-up in total). No BSCM-associated mortality was observed in our conservatively as well as surgically managed patient cohort. Our systematic literature review and analysis revealed an overall BSCM-associated mortality rate of 2.3% (95% CI: 1.6-3.3) in 22 studies comprising 1,251 patients managed conservatively and of 1.3% (95% CI: 0.9-1.7) in 99 studies comprising 3,275 patients with BSCM treated surgically. CONCLUSION The BSCM-associated mortality rate in patients managed conservatively is almost as low as in patients treated surgically and much lower than in frequently cited reports, most probably due to the good selection nowadays in regard to surgery.
Collapse
Affiliation(s)
- Julia Velz
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Marian Christoph Neidert
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland.,Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Yang Yang
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland.,Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Kevin Akeret
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Peter Nakaji
- Department of Neurosurgery at Banner, University Medical Center Phoenix, Phoenix, Arizona, USA
| | - Luca Regli
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Oliver Bozinov
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland.,Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| |
Collapse
|
22
|
Akeret K, van Niftrik CHB, Sebök M, Muscas G, Visser T, Staartjes VE, Marinoni F, Serra C, Regli L, Krayenbühl N, Piccirelli M, Fierstra J. Topographic volume-standardization atlas of the human brain. Brain Struct Funct 2021; 226:1699-1711. [PMID: 33961092 PMCID: PMC8203509 DOI: 10.1007/s00429-021-02280-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 11/28/2020] [Accepted: 04/10/2021] [Indexed: 11/29/2022]
Abstract
Specific anatomical patterns are seen in various diseases affecting the brain. Clinical studies on the topography of pathologies are often limited by the absence of a normalization of the prevalence of pathologies to the relative volume of the affected anatomical structures. A comprehensive reference on the relative volumes of clinically relevant anatomical structures serving for such a normalization, is currently lacking. The analyses are based on anatomical high-resolution three-dimensional T1-weighted magnetic resonance imaging data of 30 healthy Caucasian volunteers, including 14 females (mean age 37.79 years, SD 13.04) and 16 males (mean age 38.31 years, SD 16.91). Semi-automated anatomical segmentation was used, guided by a neuroanatomical parcellation algorithm differentiating 96 structures. Relative volumes were derived by normalizing parenchymal structures to the total individual encephalic volume and ventricular segments to the total individual ventricular volume. The present investigation provides the absolute and relative volumes of 96 anatomical parcellation units of the human encephalon. A larger absolute volume in males than in females is found for almost all parcellation units. While parenchymal structures display a trend towards decreasing volumes with increasing age, a significant inverse effect is seen with the ventricular system. The variances in volumes as well as the effects of gender and age are given for each structure before and after normalization. The provided atlas constitutes an anatomically detailed and comprehensive analysis of the absolute and relative volumes of the human encephalic structures using a clinically oriented parcellation algorithm. It is intended to serve as a reference for volume-standardization in clinical studies on the topographic prevalence of pathologies.
Collapse
Affiliation(s)
- Kevin Akeret
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland.
| | - Christiaan Hendrik Bas van Niftrik
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Martina Sebök
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Giovanni Muscas
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Thomas Visser
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Victor E Staartjes
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Federica Marinoni
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Carlo Serra
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Niklaus Krayenbühl
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland.,Division of Pediatric Neurosurgery, University Children's Hospital, Zurich, Switzerland
| | - Marco Piccirelli
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Jorn Fierstra
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| |
Collapse
|
23
|
Terrapon APR, Zattra CM, Voglis S, Velz J, Vasella F, Akeret K, Held U, Schiavolin S, Bozinov O, Ferroli P, Broggi M, Sarnthein J, Regli L, Neidert MC. Adverse Events in Neurosurgery: The Novel Therapy-Disability-Neurology Grade. Neurosurgery 2021; 89:236-245. [PMID: 33887774 DOI: 10.1093/neuros/nyab121] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [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: 11/24/2020] [Accepted: 02/14/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The most widely used classifications of adverse events (AEs) in neurosurgery define their severity according to the therapy used to treat them. This concept has substantial shortcomings because it does not reflect the severity of AEs that are not treated, such as new neurological deficits. OBJECTIVE To present a novel multidimensional and patient-centered classification of the severity of AE in neurosurgery and evaluate its applicability. METHODS The Therapy-Disability-Neurology (TDN) grading system classifies AEs depending on the associated therapy, disability, and neurological deficits. We conducted a 2-center retrospective observational study on 6071 interventions covering the whole neurosurgical spectrum with data prospectively recorded between 2013 and 2019 at 2 institutions from 2 countries. RESULTS Using the first patient cohort (4680 interventions), a positive correlation was found between severity of AE and LOS as well as treatment cost. Each grade was associated with a greater deterioration of the Karnofsky Performance Status Scale (KPS) at discharge and at follow-up. When using the same methods on the external validation cohort (1391 interventions), correlations between the grades of AE, LOS, and KPS at discharge were even more pronounced. CONCLUSION Our results suggest that the TDN grade is consistent with clinical and economic repercussions of AE and thus reflects AE severity. It is easily interpreted and enables comparison between different medical centers. The standardized report of the severity of AE in the scientific literature could constitute an important step forward toward a more critical, patient-centered, and evidence-based decision-making in neurosurgery.
Collapse
Affiliation(s)
- Alexis Paul Romain Terrapon
- Department of Neurosurgery and Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland.,Department of Neurosurgery, Kantonsspital St. Gallen and Medical School St. Gallen, St. Gallen, Switzerland
| | - Costanza Maria Zattra
- Department of Neurosurge, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Stefanos Voglis
- Department of Neurosurgery and Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Julia Velz
- Department of Neurosurgery and Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Flavio Vasella
- Department of Neurosurgery and Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Kevin Akeret
- Department of Neurosurgery and Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Ulrike Held
- Department of Biostatistics at Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Silvia Schiavolin
- Neurology, Public Health and Disability Unit, Fondazione IRCSS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Oliver Bozinov
- Department of Neurosurgery and Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland.,Department of Neurosurgery, Kantonsspital St. Gallen and Medical School St. Gallen, St. Gallen, Switzerland
| | - Paolo Ferroli
- Department of Neurosurge, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Morgan Broggi
- Department of Neurosurge, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Johannes Sarnthein
- Department of Neurosurgery and Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery and Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Marian Christoph Neidert
- Department of Neurosurgery and Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland.,Department of Neurosurgery, Kantonsspital St. Gallen and Medical School St. Gallen, St. Gallen, Switzerland
| |
Collapse
|
24
|
Serra C, Akeret K, Staartjes VE, Ramantani G, Grunwald T, Jokeit H, Bauer J, Krayenbühl N. Safety of the paramedian supracerebellar-transtentorial approach for selective amygdalohippocampectomy. Neurosurg Focus 2021; 48:E4. [PMID: 32234984 DOI: 10.3171/2020.1.focus19909] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 01/24/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The goal of this study was to assess the reproducibility and safety of the recently introduced paramedian supracerebellar-transtentorial (PST) approach for selective amygdalohippocampectomy (SA). METHODS The authors performed a retrospective analysis of prospectively collected data originating from their surgical register of patients undergoing SA via a PST approach for lesional medial temporal lobe epilepsy. All patients received thorough pre- and postoperative clinical (neurological, neuropsychological, psychiatric) and instrumental (ictal and long-term EEG, invasive EEG if needed, MRI) workup. Surgery-induced complications were assessed at discharge and at every follow-up thereafter and were classified according to Clavien-Dindo grade (CDG). Epilepsy outcome was defined according to Engel classification. Data were reported according to common descriptive statistical methods. RESULTS Between May 2015 and May 2018, 17 patients underwent SA via a PST approach at the authors' institution (hippocampal sclerosis in 13 cases, WHO grade II glioma in 2 cases, and reactive gliosis in 2 cases). The median postoperative follow-up was 7 months (mean 9 months, range 3-19 months). There was no surgery-related mortality and no complication (CDG ≥ 2) in the whole series. Transitory CDG 1 surgical complications occurred in 4 patients and had resolved in all of them by the first postoperative follow-up. One patient showed a deterioration of neuropsychological performance with new slight mnestic deficits. No patient experienced a clinically relevant postoperative visual field defect. No morbidity due to semisitting position was recorded. At last follow-up 13/17 (76.4%) patients were in Engel class I (9/17 [52.9%] were in class IA). CONCLUSIONS The PST approach is a reproducible and safe surgical route for SA. The achievable complication rate is in line with the best results in the literature. Visual function outcome particularly benefits from this highly selective, neocortex-sparing approach. A larger patient sample and longer follow-up will show in the future if the seizure control rate and neuropsychological outcome also compare better than those achieved with current common surgical techniques.
Collapse
Affiliation(s)
- Carlo Serra
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich
| | - Kevin Akeret
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich
| | - Victor E Staartjes
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich
| | - Georgia Ramantani
- 2Division of Pediatric Neurology, University Children's Hospital, Zurich
| | - Thomas Grunwald
- 3Department of Neuropsychology, Swiss Epilepsy Clinic, Klinik Lengg AG, Zurich; and
| | - Hennric Jokeit
- 3Department of Neuropsychology, Swiss Epilepsy Clinic, Klinik Lengg AG, Zurich; and
| | - Julia Bauer
- 3Department of Neuropsychology, Swiss Epilepsy Clinic, Klinik Lengg AG, Zurich; and
| | - Niklaus Krayenbühl
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich.,4Division of Pediatric Neurosurgery, Children's University Hospital Zurich, Switzerland
| |
Collapse
|
25
|
Akeret K, Stumpo V, Staartjes VE, Vasella F, Velz J, Marinoni F, Dufour JP, Imbach LL, Regli L, Serra C, Krayenbühl N. Topographic brain tumor anatomy drives seizure risk and enables machine learning based prediction. Neuroimage Clin 2020; 28:102506. [PMID: 33395995 PMCID: PMC7711280 DOI: 10.1016/j.nicl.2020.102506] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 10/05/2020] [Accepted: 11/10/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The aim of this study was to identify relevant risk factors for epileptic seizures upon initial diagnosis of a brain tumor and to develop and validate a machine learning based prediction to allow for a tailored risk-based antiepileptic therapy. METHODS Clinical, electrophysiological and high-resolution imaging data was obtained from a consecutive cohort of 1051 patients with newly diagnosed brain tumors. Factor-associated seizure risk difference allowed to determine the relevance of specific topographic, demographic and histopathologic variables available at the time of diagnosis for seizure risk. The data was divided in a 70/30 ratio into a training and test set. Different machine learning based predictive models were evaluated before a generalized additive model (GAM) was selected considering its traceability while maintaining high performance. Based on a clinical stratification of the risk factors, three different GAM were trained and internally validated. RESULTS A total of 923 patients had full data and were included. Specific topographic anatomical patterns that drive seizure risk could be identified. The involvement of allopallial, mesopallial or primary motor/somatosensory neopallial structures by brain tumors results in a significant and clinically relevant increase in seizure risk. While topographic input was most relevant for the GAM, the best prediction was achieved by a combination of topographic, demographic and histopathologic information (Validation: AUC: 0.79, Accuracy: 0.72, Sensitivity: 0.81, Specificity: 0.66). CONCLUSIONS This study identifies specific phylogenetic anatomical patterns as epileptic drivers. A GAM allowed the prediction of seizure risk using topographic, demographic and histopathologic data achieving fair performance while maintaining transparency.
Collapse
Affiliation(s)
- Kevin Akeret
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
| | - Vittorio Stumpo
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Institute of Neurosurgery, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Victor E Staartjes
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Amsterdam UMC, Vrije Universiteit Amsterdam, Neurosurgery, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Flavio Vasella
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Julia Velz
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Federica Marinoni
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Jean-Philippe Dufour
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Lukas L Imbach
- Division of Epileptology, Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Carlo Serra
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Niklaus Krayenbühl
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Division of Pediatric Neurosurgery, University Children's Hospital, Zurich, Switzerland
| |
Collapse
|
26
|
Velz J, Vasella F, Akeret K, Dias S, Jehli E, Bozinov O, Regli L, Germans MR, Stienen MN. Patterns of care: burr-hole cover application for chronic subdural hematoma trepanation. Neurosurg Focus 2020; 47:E14. [PMID: 31675709 DOI: 10.3171/2019.8.focus19245] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 03/12/2019] [Accepted: 08/14/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Skin depressions may appear as undesired effects after burr-hole trepanation for the evacuation of chronic subdural hematomas (cSDH). Placement of burr-hole covers to reconstruct skull defects can prevent skin depressions, with the potential to improve the aesthetic result and patient satisfaction. The perception of the relevance of this practice, however, appears to vary substantially among neurosurgeons. The authors aimed to identify current practice variations with regard to the application of burr-hole covers after trepanation for cSDH. METHODS An electronic survey containing 12 questions was sent to resident and faculty neurosurgeons practicing in different parts of the world, as identified by an Internet search. All responses completed between September 2018 and December 2018 were considered. Descriptive statistics and logistic regression were used to analyze the data. RESULTS A total of 604 responses were obtained, of which 576 (95.4%) provided complete data. The respondents' mean age was 42.4 years (SD 10.5), and 86.5% were male. The sample consisted of residents, fellows, junior/senior consultants, and department chairs from 79 countries (77.4% Europe, 11.8% Asia, 5.4% America, 3.5% Africa, and 1.9% Australasia). Skin depressions were considered a relevant issue by 31.6%, and 76.0% indicated that patients complain about skin depressions more or less frequently. Burr-hole covers are placed by 28.1% in the context of cSDH evacuation more or less frequently. The most frequent reasons for not placing a burr-hole cover were the lack of proven benefit (34.8%), followed by additional costs (21.9%), technical difficulty (19.9%), and fear of increased complications (4.9%). Most respondents (77.5%) stated that they would consider placing burr-hole covers in the future if there was evidence for superiority of the practice. The use of burr-hole covers varied substantially across countries, but a country's gross domestic product per capita was not associated with their placement. CONCLUSIONS Only a minority of neurosurgeons place burr-hole covers after trepanation for cSDH on a regular basis, even though the majority of participants reported complaints from patients regarding postoperative skin depressions. There are significant differences in the patterns of care among countries. Class I evidence with regard to patient satisfaction and safety of burr-hole cover placement is likely to have an impact on future cSDH management.
Collapse
Affiliation(s)
- Julia Velz
- 1Department of Neurosurgery, University Hospital Zurich; and.,2Clinical Neuroscience Center, University of Zurich, Switzerland
| | - Flavio Vasella
- 1Department of Neurosurgery, University Hospital Zurich; and.,2Clinical Neuroscience Center, University of Zurich, Switzerland
| | - Kevin Akeret
- 1Department of Neurosurgery, University Hospital Zurich; and.,2Clinical Neuroscience Center, University of Zurich, Switzerland
| | - Sandra Dias
- 1Department of Neurosurgery, University Hospital Zurich; and.,2Clinical Neuroscience Center, University of Zurich, Switzerland
| | - Elisabeth Jehli
- 1Department of Neurosurgery, University Hospital Zurich; and.,2Clinical Neuroscience Center, University of Zurich, Switzerland
| | - Oliver Bozinov
- 1Department of Neurosurgery, University Hospital Zurich; and.,2Clinical Neuroscience Center, University of Zurich, Switzerland
| | - Luca Regli
- 1Department of Neurosurgery, University Hospital Zurich; and.,2Clinical Neuroscience Center, University of Zurich, Switzerland
| | - Menno R Germans
- 1Department of Neurosurgery, University Hospital Zurich; and.,2Clinical Neuroscience Center, University of Zurich, Switzerland
| | - Martin N Stienen
- 1Department of Neurosurgery, University Hospital Zurich; and.,2Clinical Neuroscience Center, University of Zurich, Switzerland
| | | |
Collapse
|
27
|
Hugelshofer M, Buzzi RM, Schaer CA, Richter H, Akeret K, Anagnostakou V, Mahmoudi L, Vaccani R, Vallelian F, Deuel JW, Kronen PW, Kulcsar Z, Regli L, Baek JH, Pires IS, Palmer AF, Dennler M, Humar R, Buehler PW, Kircher PR, Keller E, Schaer DJ. Haptoglobin administration into the subarachnoid space prevents hemoglobin-induced cerebral vasospasm. J Clin Invest 2020; 129:5219-5235. [PMID: 31454333 DOI: 10.1172/jci130630] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [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: 05/30/2019] [Accepted: 08/20/2019] [Indexed: 12/13/2022] Open
Abstract
Delayed ischemic neurological deficit (DIND) is a major driver of adverse outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH), defining an unmet need for therapeutic development. Cell-free hemoglobin that is released from erythrocytes into the cerebrospinal fluid (CSF) is suggested to cause vasoconstriction and neuronal toxicity, and correlates with the occurrence of DIND. Cell-free hemoglobin in the CSF of patients with aSAH disrupted dilatory NO signaling ex vivo in cerebral arteries, which shifted vascular tone balance from dilation to constriction. We found that selective removal of hemoglobin from patient CSF with a haptoglobin-affinity column or its sequestration in a soluble hemoglobin-haptoglobin complex was sufficient to restore physiological vascular responses. In a sheep model, administration of haptoglobin into the CSF inhibited hemoglobin-induced cerebral vasospasm and preserved vascular NO signaling. We identified 2 pathways of hemoglobin delocalization from CSF into the brain parenchyma and into the NO-sensitive compartment of small cerebral arteries. Both pathways were critical for hemoglobin toxicity and were interrupted by the large hemoglobin-haptoglobin complex that inhibited spatial requirements for hemoglobin reactions with NO in tissues. Collectively, our data show that compartmentalization of hemoglobin by haptoglobin provides a novel framework for innovation aimed at reducing hemoglobin-driven neurological damage after subarachnoid bleeding.
Collapse
Affiliation(s)
- Michael Hugelshofer
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Raphael M Buzzi
- Division of Internal Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Christian A Schaer
- Division of Internal Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Henning Richter
- Clinic for Diagnostic Imaging, Department of Clinical Diagnostics and Services, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | - Kevin Akeret
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Vania Anagnostakou
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Leila Mahmoudi
- Division of Internal Medicine, University Hospital of Zurich, Zurich, Switzerland.,Department of Chemistry and Applied Biosciences, ETH Zurich, Zurich, Switzerland
| | - Raphael Vaccani
- Division of Internal Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Florence Vallelian
- Division of Internal Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Jeremy W Deuel
- Division of Internal Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Peter W Kronen
- Veterinary Anaesthesia Services - International, Winterthur, Switzerland.,Center for Applied Biotechnology and Molecular Medicine (CABMM), University of Zurich, Zurich, Switzerland
| | - Zsolt Kulcsar
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Jin Hyen Baek
- Center of Biologics Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Ivan S Pires
- William G. Lowrie Department of Chemical and Biomolecular Engineering, The Ohio State University, Columbus, Ohio, USA
| | - Andre F Palmer
- William G. Lowrie Department of Chemical and Biomolecular Engineering, The Ohio State University, Columbus, Ohio, USA
| | - Matthias Dennler
- Clinic for Diagnostic Imaging, Department of Clinical Diagnostics and Services, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | - Rok Humar
- Division of Internal Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Paul W Buehler
- Center of Biologics Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Patrick R Kircher
- Clinic for Diagnostic Imaging, Department of Clinical Diagnostics and Services, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | - Emanuela Keller
- Neurointensive Care Unit, University Hospital of Zurich, Zurich, Switzerland
| | - Dominik J Schaer
- Division of Internal Medicine, University Hospital of Zurich, Zurich, Switzerland
| |
Collapse
|
28
|
van Niftrik CHB, van der Wouden F, Staartjes VE, Fierstra J, Stienen MN, Akeret K, Sebök M, Fedele T, Sarnthein J, Bozinov O, Krayenbühl N, Regli L, Serra C. Machine Learning Algorithm Identifies Patients at High Risk for Early Complications After Intracranial Tumor Surgery: Registry-Based Cohort Study. Neurosurgery 2020; 85:E756-E764. [PMID: 31149726 DOI: 10.1093/neuros/nyz145] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [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: 08/21/2018] [Accepted: 01/12/2019] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Reliable preoperative identification of patients at high risk for early postoperative complications occurring within 24 h (EPC) of intracranial tumor surgery can improve patient safety and postoperative management. Statistical analysis using machine learning algorithms may generate models that predict EPC better than conventional statistical methods. OBJECTIVE To train such a model and to assess its predictive ability. METHODS This cohort study included patients from an ongoing prospective patient registry at a single tertiary care center with an intracranial tumor that underwent elective neurosurgery between June 2015 and May 2017. EPC were categorized based on the Clavien-Dindo classification score. Conventional statistical methods and different machine learning algorithms were used to predict EPC using preoperatively available patient, clinical, and surgery-related variables. The performance of each model was derived from examining classification performance metrics on an out-of-sample test dataset. RESULTS EPC occurred in 174 (26%) of 668 patients included in the analysis. Gradient boosting machine learning algorithms provided the model best predicting the probability of an EPC. The model scored an accuracy of 0.70 (confidence interval [CI] 0.59-0.79) with an area under the curve (AUC) of 0.73 and a sensitivity and specificity of 0.80 (CI 0.58-0.91) and 0.67 (CI 0.53-0.77) on the test set. The conventional statistical model showed inferior predictive power (test set: accuracy: 0.59 (CI 0.47-0.71); AUC: 0.64; sensitivity: 0.76 (CI 0.64-0.85); specificity: 0.53 (CI 0.41-0.64)). CONCLUSION Using gradient boosting machine learning algorithms, it was possible to create a prediction model superior to conventional statistical methods. While conventional statistical methods favor patients' characteristics, we found the pathology and surgery-related (histology, anatomical localization, surgical access) variables to be better predictors of EPC.
Collapse
Affiliation(s)
- Christiaan H B van Niftrik
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland.,Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Frank van der Wouden
- Department of Geography, University of California - Los Angeles, United States of America.,Management and Organizations Department, Kellogg School of Management, Northwestern University, Evanston, Illinois
| | - Victor E Staartjes
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland.,Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Jorn Fierstra
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland.,Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Martin N Stienen
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland.,Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Kevin Akeret
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland.,Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Martina Sebök
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland.,Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Tommaso Fedele
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland.,Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Johannes Sarnthein
- Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Oliver Bozinov
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland.,Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Niklaus Krayenbühl
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland.,Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland.,Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Carlo Serra
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland.,Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| |
Collapse
|
29
|
Stienen MN, Akeret K, Vasella F, Velz J, Jehli E, Scheffler P, Voglis S, Bichsel O, Smoll NR, Bozinov O, Regli L, Germans MR. COveRs to impRove AesthetiC ouTcome after Surgery for Chronic subdural haemAtoma by buRr hole trepanation (CORRECT-SCAR): protocol of a Swiss single-blinded, randomised controlled trial. BMJ Open 2019; 9:e031375. [PMID: 31811007 PMCID: PMC6924766 DOI: 10.1136/bmjopen-2019-031375] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Outcomes rated on impairment scales are satisfactory after burr hole trepanation for chronic subdural haematoma (cSDH). However, the surgery leads to bony defects in the skull with skin depressions above that are frequently considered aesthetically unsatisfactory by the patients. Those defects could be covered by the approved medical devices (burr hole covers), but this is rarely done today. We wish to assess, whether the application of burr hole covers after trepanation for the evacuation of cSDH leads to higher patient satisfaction with the aesthetical result at 90 days postoperative, without worsening disability outcomes or increasing the complication rate. METHODS AND ANALYSIS This is a prospective, single-blinded, randomised, controlled, investigator-initiated clinical trial enrolling 80 adult patients with first-time unilateral or bilateral cSDH in Switzerland. The primary outcome is the difference in satisfaction with the aesthetic result of the scar, comparing patients allocated to the intervention (burr hole cover) and control (no burr hole cover) group, measured on the Aesthetic Numeric Analogue scale at 90 days postoperative. Secondary outcomes include differences in the rates of skin depression, complications, as well as neurological, disability and health-related quality of life outcomes until 12 months postoperative. ETHICS AND DISSEMINATION The institutional review board (Kantonale Ethikkommission Zürich) approved this study on 29 January 2019 under case number BASEC 2018-01180. This study determines, whether a relatively minor modification of a standard surgical procedure can improve patient satisfaction, without worsening functional outcomes or increasing the complication rate. The outcome corresponds to the value-based medicine approach of modern patient-centred medicine. Results will be published in peer-reviewed journals and electronic patient data will be safely stored for 15 years. TRIAL REGISTRATION NUMBER NCT03755349.
Collapse
Affiliation(s)
- Martin N Stienen
- Department of Neurosurgery, University Hospital Zurich, Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Kevin Akeret
- Department of Neurosurgery, University Hospital Zurich, Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Flavio Vasella
- Department of Neurosurgery, University Hospital Zurich, Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Julia Velz
- Department of Neurosurgery, University Hospital Zurich, Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Elisabeth Jehli
- Department of Neurosurgery, University Hospital Zurich, Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Pierre Scheffler
- Department of Neurosurgery, University Hospital Zurich, Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Stefanos Voglis
- Department of Neurosurgery, University Hospital Zurich, Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Oliver Bichsel
- Department of Neurosurgery, University Hospital Zurich, Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Nicolas Roydon Smoll
- School of Population and Global Health, University of Melbourne, Melbourne, Sydney, Australia
| | - Oliver Bozinov
- Department of Neurosurgery, University Hospital Zurich, Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, University Hospital Zurich, Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Menno R Germans
- Department of Neurosurgery, University Hospital Zurich, Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| |
Collapse
|
30
|
Akeret K, Bellut D, Huppertz HJ, Ramantani G, König K, Serra C, Regli L, Krayenbühl N. Ultrasonographic features of focal cortical dysplasia and their relevance for epilepsy surgery. Neurosurg Focus 2019; 45:E5. [PMID: 30173618 DOI: 10.3171/2018.6.focus18221] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 11/06/2022]
Abstract
OBJECTIVE Surgery has proven to be the best therapeutic option for drug-refractory cases of focal cortical dysplasia (FCD)-associated epilepsy. Seizure outcome primarily depends on the completeness of resection, rendering the intraoperative FCD identification and delineation particularly important. This study aims to assess the diagnostic yield of intraoperative ultrasound (IOUS) in surgery for FCD-associated drug-refractory epilepsy. METHODS The authors prospectively enrolled 15 consecutive patients with drug-refractory epilepsy who underwent an IOUS-assisted microsurgical resection of a radiologically suspected FCD between January 2013 and July 2016. The findings of IOUS were compared with those of presurgical MRI postprocessing and the sonographic characteristics were analyzed in relation to the histopathological findings. The authors investigated the added value of IOUS in achieving completeness of resection and improving postsurgical seizure outcome. RESULTS The neurosurgeon was able to identify the dysplastic tissue by IOUS in all cases. The visualization of FCD type I was more challenging compared to FCD II and the demarcation of its borders was less clear. Postsurgical MRI showed residual dysplasia in 2 of the 3 patients with FCD type I. In all FCD type II cases, IOUS allowed for a clear intraoperative visualization and demarcation, strongly correlating with presurgical MRI postprocessing. Postsurgical MRI confirmed complete resection in all FCD type II cases. Sonographic features correlated with the histopathological classification of dysplasia (sonographic abnormalities increase continuously in the following order: FCD IA/IB, FCD IC, FCD IIA, FCD IIB). In 1 patient with IOUS features atypical for FCD, histopathological investigation showed nonspecific gliosis. CONCLUSIONS Morphological features of FCD, as identified by IOUS, correlate well with advanced presurgical imaging. The resolution of IOUS was superior to MRI in all FCD types. The appreciation of distinct sonographic features on IOUS allows the intraoperative differentiation between FCD and non-FCD lesions as well as the discrimination of different histological subtypes of FCD. Sonographic demarcation depends on the underlying degree of dysplasia. IOUS allows for more tailored resections by facilitating the delineation of the dysplastic tissue.
Collapse
Affiliation(s)
- Kevin Akeret
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich
| | - David Bellut
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich
| | | | - Georgia Ramantani
- 3Division of Pediatric Neurology, University Children's Hospital, Zurich; and.,4Swiss Epilepsy Clinic, Klinik Lengg AG, Zurich, Switzerland
| | - Kristina König
- 4Swiss Epilepsy Clinic, Klinik Lengg AG, Zurich, Switzerland
| | - Carlo Serra
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich
| | - Luca Regli
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich
| | - Niklaus Krayenbühl
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich.,2Division of Pediatric Neurosurgery, University Children's Hospital, Zurich
| |
Collapse
|
31
|
Staartjes VE, Serra C, Muscas G, Maldaner N, Akeret K, van Niftrik CHB, Fierstra J, Holzmann D, Regli L. Utility of deep neural networks in predicting gross-total resection after transsphenoidal surgery for pituitary adenoma: a pilot study. Neurosurg Focus 2019; 45:E12. [PMID: 30453454 DOI: 10.3171/2018.8.focus18243] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [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: 05/19/2018] [Accepted: 08/20/2018] [Indexed: 12/20/2022]
Abstract
OBJECTIVEGross-total resection (GTR) is often the primary surgical goal in transsphenoidal surgery for pituitary adenoma. Existing classifications are effective at predicting GTR but are often hampered by limited discriminatory ability in moderate cases and by poor interrater agreement. Deep learning, a subset of machine learning, has recently established itself as highly effective in forecasting medical outcomes. In this pilot study, the authors aimed to evaluate the utility of using deep learning to predict GTR after transsphenoidal surgery for pituitary adenoma.METHODSData from a prospective registry were used. The authors trained a deep neural network to predict GTR from 16 preoperatively available radiological and procedural variables. Class imbalance adjustment, cross-validation, and random dropout were applied to prevent overfitting and ensure robustness of the predictive model. The authors subsequently compared the deep learning model to a conventional logistic regression model and to the Knosp classification as a gold standard.RESULTSOverall, 140 patients who underwent endoscopic transsphenoidal surgery were included. GTR was achieved in 95 patients (68%), with a mean extent of resection of 96.8% ± 10.6%. Intraoperative high-field MRI was used in 116 (83%) procedures. The deep learning model achieved excellent area under the curve (AUC; 0.96), accuracy (91%), sensitivity (94%), and specificity (89%). This represents an improvement in comparison with the Knosp classification (AUC: 0.87, accuracy: 81%, sensitivity: 92%, specificity: 70%) and a statistically significant improvement in comparison with logistic regression (AUC: 0.86, accuracy: 82%, sensitivity: 81%, specificity: 83%) (all p < 0.001).CONCLUSIONSIn this pilot study, the authors demonstrated the utility of applying deep learning to preoperatively predict the likelihood of GTR with excellent performance. Further training and validation in a prospective multicentric cohort will enable the development of an easy-to-use interface for use in clinical practice.
Collapse
Affiliation(s)
- Victor E Staartjes
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Carlo Serra
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Giovanni Muscas
- 2Department of Neurosurgery, Tuscany School of Neurosurgery, University of Firenze, Italy; and
| | - Nicolai Maldaner
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Kevin Akeret
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Christiaan H B van Niftrik
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Jorn Fierstra
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - David Holzmann
- 3Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, University of Zurich, Switzerland
| | - Luca Regli
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| |
Collapse
|
32
|
Staartjes VE, Zattra CM, Akeret K, Maldaner N, Muscas G, Bas van Niftrik CH, Fierstra J, Regli L, Serra C. Neural network-based identification of patients at high risk for intraoperative cerebrospinal fluid leaks in endoscopic pituitary surgery. J Neurosurg 2019; 133:1-7. [PMID: 31226693 DOI: 10.3171/2019.4.jns19477] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [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: 02/19/2019] [Accepted: 04/08/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Although rates of postoperative morbidity and mortality have become relatively low in patients undergoing transnasal transsphenoidal surgery (TSS) for pituitary adenoma, cerebrospinal fluid (CSF) fistulas remain a major driver of postoperative morbidity. Persistent CSF fistulas harbor the potential for headache and meningitis. The aim of this study was to investigate whether neural network-based models can reliably identify patients at high risk for intraoperative CSF leakage. METHODS From a prospective registry, patients who underwent endoscopic TSS for pituitary adenoma were identified. Risk factors for intraoperative CSF leaks were identified using conventional statistical methods. Subsequently, the authors built a prediction model for intraoperative CSF leaks based on deep learning. RESULTS Intraoperative CSF leaks occurred in 45 (29%) of 154 patients. No risk factors for CSF leaks were identified using conventional statistical methods. The deep neural network-based prediction model classified 88% of patients in the test set correctly, with an area under the curve of 0.84. Sensitivity (83%) and specificity (89%) were high. The positive predictive value was 71%, negative predictive value was 94%, and F1 score was 0.77. High suprasellar Hardy grade, prior surgery, and older age contributed most to the predictions. CONCLUSIONS The authors trained and internally validated a robust deep neural network-based prediction model that identifies patients at high risk for intraoperative CSF. Machine learning algorithms may predict outcomes and adverse events that were previously nearly unpredictable, thus enabling safer and improved patient care and better patient counseling.
Collapse
Affiliation(s)
- Victor E Staartjes
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- 2Amsterdam UMC, Vrije Universiteit Amsterdam, Neurosurgery, Amsterdam Movement Sciences, Amsterdam, The Netherlands; and
| | - Costanza M Zattra
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Kevin Akeret
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Nicolai Maldaner
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Giovanni Muscas
- 3Department of Neurosurgery, Tuscany School of Neurosurgery, University of Firenze, Firenze, Italy
| | | | - Jorn Fierstra
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Luca Regli
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Carlo Serra
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| |
Collapse
|
33
|
Serra C, Staartjes VE, Maldaner N, Muscas G, Akeret K, Holzmann D, Soyka MB, Schmid C, Regli L. Response to "Going beyond scoring systems for cavernous sinus involvement in trans-sphenoidal pituitary surgery". Acta Neurochir (Wien) 2019; 161:1035-1036. [PMID: 30953155 DOI: 10.1007/s00701-019-03891-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 03/25/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Carlo Serra
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse10, 8091, Zurich, Switzerland.
| | - Victor E Staartjes
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse10, 8091, Zurich, Switzerland
| | - Nicolai Maldaner
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse10, 8091, Zurich, Switzerland
| | - Giovanni Muscas
- Department of Neurosurgery, Tuscany School of Neurosurgery, University of Firenze, Florence, Italy
| | - Kevin Akeret
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse10, 8091, Zurich, Switzerland
| | - David Holzmann
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Michael B Soyka
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Christoph Schmid
- Department of Endocrinology and Diabetes, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse10, 8091, Zurich, Switzerland
| |
Collapse
|
34
|
Akeret K, Germans M, Sun W, Kulcsar Z, Regli L. Subarachnoid Hemorrhage Due to Flow-Related Dissection of the Posterior-Inferior Cerebellar Artery Associated with a Distal Arteriovenous Malformation. World Neurosurg 2019; 125:44-48. [PMID: 30721771 DOI: 10.1016/j.wneu.2019.01.148] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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: 12/07/2018] [Revised: 01/15/2019] [Accepted: 01/17/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cerebral arteriovenous malformations (CAVMs) are characterized by altered hemodynamics and associated with angioanatomic changes, such as aneurysms. We encountered a patient with a CAVM-associated dissection of the medial trunk of the posterior inferior cerebellar artery (PICA) instead of an aneurysm. CASE DESCRIPTION We report the case of a 56-year-old male patient with spontaneous subarachnoid hemorrhage within the cisterna magna and fourth ventricle. Digital subtraction angiography revealed a cerebellar arteriovenous malformation located within the inferior semilunar lobule that did not anatomically match the bleeding pattern. The left PICA, serving as a primary feeding artery, showed a dissection of the proximal portion of the medial trunk with a precise anatomic association with the blood in the telovelotonsillar space. CAVM-induced hyperdynamic flow through the feeding vessel is the most plausible pathophysiologic explanation for the dissection. Complete microsurgical resection of the CAVM was performed, and 3-month follow-up digital subtraction angiography showed complete regression of the dissection, disappearance of irregularities, and significant caliber reduction of the medial PICA trunk. CONCLUSIONS This is the first report of a hyperdynamic flow-related dissection of a CAVM-associated feeding vessel. Microsurgical resection of the CAVM allowed for spontaneous resolution of the dissected area by restoration of normal rheodynamics.
Collapse
Affiliation(s)
- Kevin Akeret
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
| | - Menno Germans
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Wenhua Sun
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Zsolt Kulcsar
- Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Department of Neuroradiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| |
Collapse
|
35
|
Akeret K, Serra C, Rafi O, Staartjes VE, Fierstra J, Bellut D, Maldaner N, Imbach LL, Wolpert F, Poryazova R, Regli L, Krayenbühl N. Anatomical features of primary brain tumors affect seizure risk and semiology. Neuroimage Clin 2019; 22:101688. [PMID: 30710869 PMCID: PMC6354289 DOI: 10.1016/j.nicl.2019.101688] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 01/19/2019] [Accepted: 01/22/2019] [Indexed: 11/23/2022]
Abstract
Objective An epileptic seizure is the most common clinical manifestation of a primary brain tumor. Due to modern neuroimaging, detailed anatomical information on a brain tumor is available early in the diagnostic process and therefore carries considerable potential in clinical decision making. The goal of this study was to gain a better understanding of the relevance of anatomical tumor characteristics on seizure prevalence and semiology. Methods We reviewed prospectively collected clinical and imaging data of all patients operated on a supratentorial intraparenchymal primary brain tumor at our department between January 2009 and December 2016. The effect of tumor histology, anatomical location and white matter infiltration on seizure prevalence and semiology were assessed using uni- and multivariate analyses. Results Of 678 included patients, 311 (45.9%) presented with epileptic seizures. Tumor location within the central lobe was associated with higher seizure prevalence (OR 4.67, 95% CI: 1.90–13.3, p = .002), especially within the precentral gyrus or paracentral lobule (100%). Bilateral extension, location within subcortical structures and invasion of deeper white matter sectors were associated with a lower risk (OR 0.45, 95% CI: 0.25–0.78; OR 0.10, 95% CI: 0.04–0.21 and OR 0.39, 95% CI: 0.14–0.96, respectively). Multivariate analysis revealed the impact of a location within the central lobe on seizure risk to be highly significant and more relevant than histopathology (OR: 4.79, 95% CI: 1.82–14.52, p = .003). Seizures due to tumors within the central lobe differed from those of other locations by lower risk of secondary generalization (p < .001). Conclusions Topographical lobar and gyral location, as well as extent of white matter infiltration impact seizure risk and semiology. This finding may have a high therapeutic potential, for example regarding the use of prophylactic antiepileptic therapy. Brain tumor location affects seizure prevalence and semiology. Central lobe location is the strongest independent pro-epileptogenic factor. The precentral gyrus and paracentral lobule are most epileptogenic. Central lobe tumors rarely cause bilateral tonic-clonic seizures. Tumor location and white matter infiltration may guide antiepileptic therapy.
Collapse
Affiliation(s)
- Kevin Akeret
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
| | - Carlo Serra
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Omar Rafi
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Victor E Staartjes
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Jorn Fierstra
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - David Bellut
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Nicolai Maldaner
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Lukas L Imbach
- Division of Epileptology, Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Fabian Wolpert
- Division of Epileptology, Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Rositsa Poryazova
- Division of Epileptology, Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Niklaus Krayenbühl
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Division of Pediatric Neurosurgery, University Children's Hospital, Zurich, Switzerland
| |
Collapse
|
36
|
Akeret K, Vasella F, Geisseler O, Dannecker N, Ghosh A, Brugger P, Regli L, Stienen MN. Time to be "smart"-Opportunities Arising From Smartphone-Based Behavioral Analysis in Daily Patient Care. Front Behav Neurosci 2018; 12:303. [PMID: 30568582 PMCID: PMC6290758 DOI: 10.3389/fnbeh.2018.00303] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [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: 07/14/2018] [Accepted: 11/23/2018] [Indexed: 02/05/2023] Open
Abstract
While pathologies of the central nervous system (CNS) are often associated with neuropsychological deficits, adequate quantification and monitoring of such deficits remains challenging. Due to their complex nature, comprehensive neuropsychological evaluations are needed, which are time-consuming, resource-intensive and do not adequately account for daily or hourly fluctuations of a patient's condition. Innovative approaches are required to improve the diagnostics and continuous monitoring of brain function, ideally in the form of a simple, objective, time-saving and inexpensive tool that overcomes the aforementioned weaknesses of conventional assessments. As smartphones are widely used and integrated in virtually every aspect of our lives, their potential regarding the acquisition of data representing an individual's behavior and health is enormous. Alterations in a patient's physical or mental health state may be recognized as behavioral deviation from the physiological range of the normal population, but also in comparison to the patient's individual baseline assessment. As smartphone-based assessment allows for continuous monitoring and therefore accounts for possible fluctuations or transiently occurring abnormalities in a patient's neurologic state, it may serve as a surveillance tool in the acute setting for early recognition of complications, or in the long-term outpatient setting to quantify rehabilitation or disease progress. This may be particularly interesting for regions of the world where healthcare resources for comprehensive clinical/neuropsychological examinations are insufficient or distances to healthcare providers are long. Here, we highlight the potential of smartphone-based behavioral monitoring in healthcare. Clinical Trial Registration: www.clinicaltrials.gov, identifier NCT03516162.
Collapse
Affiliation(s)
- Kevin Akeret
- Department of Neurosurgery, University Hospital Zurich & Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Flavio Vasella
- Department of Neurosurgery, University Hospital Zurich & Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
- Laboratory of Molecular Neuro-Oncology, Clinical Neuroscience Center, Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Olivia Geisseler
- Neuropsychology Unit, Department of Neurology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Noemi Dannecker
- Neuropsychology Unit, Department of Neurology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Arko Ghosh
- Cognitive Psychology Unit, Institute of Psychology, Leiden University, Leiden, Netherlands
| | - Peter Brugger
- Neuropsychology Unit, Department of Neurology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, University Hospital Zurich & Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Martin N. Stienen
- Department of Neurosurgery, University Hospital Zurich & Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| |
Collapse
|
37
|
Hugelshofer M, Sikorski CM, Seule M, Deuel J, Muroi CI, Seboek M, Akeret K, Buzzi R, Regli L, Schaer DJ, Keller E. Cell-Free Oxyhemoglobin in Cerebrospinal Fluid After Aneurysmal Subarachnoid Hemorrhage: Biomarker and Potential Therapeutic Target. World Neurosurg 2018; 120:e660-e666. [DOI: 10.1016/j.wneu.2018.08.141] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 08/16/2018] [Accepted: 08/17/2018] [Indexed: 11/25/2022]
|
38
|
Serra C, Akeret K, Maldaner N, Staartjes VE, Regli L, Baltsavias G, Krayenbühl N. A White Matter Fiber Microdissection Study of the Anterior Perforated Substance and the Basal Forebrain: A Gateway to the Basal Ganglia? Oper Neurosurg (Hagerstown) 2018; 17:311-320. [DOI: 10.1093/ons/opy345] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 10/02/2018] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
Studies detailing the anatomy of the basal forebrain (BF) from a neurosurgical perspective are missing.
OBJECTIVE
To describe the anatomy of the BF and of the anterior perforated substance (APS), the BF emphasizing surgical useful anatomical relationship between surface landmarks and deep structures.
METHODS
White matter fiber microdissection was performed on 5 brain specimens to analyze the topographic anatomy of the APS and expose layer-by-layer fiber tracts and nuclei of the BF.
RESULTS
The APS, as identified anatomically, surgically, and neuroradiologically, has clear borders measured 23.3 ± 3.4 mm (19-27) in the mediolateral and 12.5 ± 1.2 mm (11-14) in the anteroposterior directions. A detailed stratigraphy of the BF was performed from the APS up to basal ganglia and thalamus allowing identification and dissection of the main components of the BF (septum, nucleus accumbens, amygdala, innominate substance) and its white matter tracts (band of Broca, extracapsular thalamic peduncle, ventral amygdalohypothalamic fibers). The olfactory trigone together with diagonal gyrus and the APS proper is a relevant superficial landmark for the basal ganglia (inferior to the nucleus accumbens, lateral to the caudate head, and medial to the lentiform nucleus).
CONCLUSION
The findings in our study supplement available anatomic knowledge of APS and BF, providing reliable landmarks for precise topographic diagnosis of BF lesions and for intraoperative orientation. Surgically relevant relationships between surface and deep anatomic structures are highlighted offering thus a contribution to neurosurgeons willing to perform surgery in this delicate area.
Collapse
Affiliation(s)
- Carlo Serra
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Kevin Akeret
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Nicolai Maldaner
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Victor E Staartjes
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Gerasimos Baltsavias
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Niklaus Krayenbühl
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| |
Collapse
|
39
|
Serra C, Staartjes VE, Maldaner N, Muscas G, Akeret K, Holzmann D, Soyka MB, Schmid C, Regli L. Predicting extent of resection in transsphenoidal surgery for pituitary adenoma. Acta Neurochir (Wien) 2018; 160:2255-2262. [PMID: 30267209 DOI: 10.1007/s00701-018-3690-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [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: 07/04/2018] [Accepted: 09/21/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND The extent of resection (EOR) is a crucial outcome parameter in transsphenoidal pituitary surgery (TSS), and is linked to endocrinological outcome, postoperative morbidity, and mortality. We aimed to build a robust, quantitative, and easily reproducible imaging score able to predict EOR in TSS. METHODS The ratio (R) between the maximum horizontal adenoma diameter and intercarotid distance at the horizontal C4 segment was used to stratify our patient series in four classes: class I R ≤ 0.75, class II 0.75 < R ≤ 1.25, and class III R ≥ 1.25. Class IV included adenomas which completely encased the internal carotid artery. The resulting score was internally validated for robustness. RESULTS One hundred sixteen patients were included in the study, of which 96 (83%) for derivation and 20 (17%) for validation. EOR showed significant differences between grades (grade I, 100%; II, 97.9%; III, 94.2%; IV, 87.2%; all P < 0.05). The same applied to residual volume (RV) (grade I, 0 cm3; II, 0.08 cm3; III, 1.11 cm3; IV, 1.63 cm3; all P < 0.05). Differences in gross total resection (GTR) were statistically significant among classes I, II, and III (P < 0.05). The incidence of residual adenoma in the cavernous sinus increased also constantly from grade I up to grade IV although a significant difference was only found between grades III and II (P = 0.004). The score performed equally well in the validation cohort. Inter-observer agreement was high, with intraclass correlation coefficients > 0.89 for measurement of both the horizontal tumor diameter and the ICD among two independent raters (P < 0.001). CONCLUSIONS The proposed score is a simple and reproducible tool which reliably predicts surgical outcome including EOR, RV, and GTR of pituitary adenoma patients undergoing TSS.
Collapse
Affiliation(s)
- Carlo Serra
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland.
| | - Victor E Staartjes
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Nicolai Maldaner
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Giovanni Muscas
- Department of Neurosurgery, Tuscany School of Neurosurgery, University of Firenze, Florence, Italy
| | - Kevin Akeret
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - David Holzmann
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Michael B Soyka
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Christoph Schmid
- Department of Endocrinology and Diabetes, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| |
Collapse
|