Erratum: Health in Germany: Establishment of a population-based health panel

[This corrects the article on p. 2,21 in vol. 9, PMID: 38282983.].

Corrigendum: Health in Germany: Establishment of a population-based health panel

[This corrects the article DOI: 10.25646/11992.2.].

Effectiveness of Lumbar Cerebrospinal Fluid Drain Among Patients With Aneurysmal Subarachnoid Hemorrhage: A Randomized Clinical Trial

Importance

After aneurysmal subarachnoid hemorrhage, the use of lumbar drains has been suggested to decrease the incidence of delayed cerebral ischemia and improve long-term outcome.

Objective

To determine the effectiveness of early lumbar cerebrospinal fluid drainage added to standard of care in patients after aneurysmal subarachnoid hemorrhage.

Design, Setting, and Participants

The EARLYDRAIN trial was a pragmatic, multicenter, parallel-group, open-label randomized clinical trial with blinded end point evaluation conducted at 19 centers in Germany, Switzerland, and Canada. The first patient entered January 31, 2011, and the last on January 24, 2016, after 307 randomizations. Follow-up was completed July 2016. Query and retrieval of data on missing items in the case report forms was completed in September 2020. A total of 20 randomizations were invalid, the main reason being lack of informed consent. No participants meeting all inclusion and exclusion criteria were excluded from the intention-to-treat analysis. Exclusion of patients was only performed in per-protocol sensitivity analysis. A total of 287 adult patients with acute aneurysmal subarachnoid hemorrhage of all clinical grades were analyzable. Aneurysm treatment with clipping or coiling was performed within 48 hours.

Intervention

A total of 144 patients were randomized to receive an additional lumbar drain after aneurysm treatment and 143 patients to standard of care only. Early lumbar drainage with 5 mL per hour was started within 72 hours of the subarachnoid hemorrhage.

Main Outcomes and Measures

Primary outcome was the rate of unfavorable outcome, defined as modified Rankin Scale score of 3 to 6 (range, 0 to 6), obtained by masked assessors 6 months after hemorrhage.

Results

Of 287 included patients, 197 (68.6%) were female, and the median (IQR) age was 55 (48-63) years. Lumbar drainage started at a median (IQR) of day 2 (1-2) after aneurysmal subarachnoid hemorrhage. At 6 months, 47 patients (32.6%) in the lumbar drain group and 64 patients (44.8%) in the standard of care group had an unfavorable neurological outcome (risk ratio, 0.73; 95% CI, 0.52 to 0.98; absolute risk difference, -0.12; 95% CI, -0.23 to -0.01; P = .04). Patients treated with a lumbar drain had fewer secondary infarctions at discharge (41 patients [28.5%] vs 57 patients [39.9%]; risk ratio, 0.71; 95% CI, 0.49 to 0.99; absolute risk difference, -0.11; 95% CI, -0.22 to 0; P = .04).

Conclusion and Relevance

In this trial, prophylactic lumbar drainage after aneurysmal subarachnoid hemorrhage lessened the burden of secondary infarction and decreased the rate of unfavorable outcome at 6 months. These findings support the use of lumbar drains after aneurysmal subarachnoid hemorrhage.

Trial Registration

ClinicalTrials.gov Identifier: NCT01258257.

Development and first results of a national databank on care and treatment outcome after traumatic brain injury

PURPOSE

In absence of comprehensive data collection on traumatic brain injury (TBI), the German Society for Neurosurgery (DGNC) and the German Society for Trauma Surgery (DGU) developed a TBI databank for German-speaking countries.

METHODS

From 2016 to 2020, the TBI databank DGNC/DGU was implemented as a module of the TraumaRegister (TR) DGU and tested in a 15-month pilot phase. Since its official launch in 2021, patients from the TR-DGU (intermediate or intensive care unit admission via shock room) with TBI (AIS head ≥ 1) can be enrolled. A data set of > 300 clinical, imaging, and laboratory variables, harmonized with other international TBI data collection structures is documented, and the treatment outcome is evaluated after 6- and 12 months.

RESULTS

For this analysis, 318 patients in the TBI databank could be included (median age 58 years; 71% men). Falls were the most common cause of injury (55%), and antithrombotic medication was frequent (28%). Severe or moderate TBI were only present in 55% of patients, while 45% suffered a mild injury. Nevertheless, intracranial pathologies were present in 95% of brain imaging with traumatic subarachnoid hemorrhages (76%) being the most common. Intracranial surgeries were performed in 42% of cases. In-hospital mortality after TBI was 21% and surviving patients could be discharged after a median hospital stay of 11 days. At the 6-and 12 months follow-up, a favorable outcome was achieved by 70% and 90% of the participating TBI patients, respectively. Compared to a European cohort of 2138 TBI patients treated in the ICU between 2014 and 2017, patients in the TBI databank were already older, frailer, fell more commonly at home.

CONCLUSION

Within five years, the TBI databank DGNC/DGU of the TR-DGU could be established and is since then prospectively enrolling TBI patients in German-speaking countries. With its large and harmonized data set and a 12-month follow-up, the TBI databank is a unique project in Europe, already allowing comparisons to other data collection structures and indicating a demographic change towards older and frailer TBI patients in Germany.

Reappraisal of Intracerebral Hemorrhages and Intracerebral Hemorrhage Grading Scale Score in Surgically and Medically Managed Cerebellar Intracerebral Hemorrhage

BACKGROUND

As compared with supratentorial intracerebral hemorrhages (ICH), bleeds that occur within the cerebellum require special consideration given the nature of the posterior fossa.

OBJECTIVE

To validate ICH and ICH grading scale (ICH-GS) scores in patients with cerebellar hemorrhage and examine the outcomes of patients managed surgically as compared with those who underwent conservative treatment.

METHODS

This observational multicenter study included 475 patients with cerebellar hemorrhage from 9 different neurosurgical departments in Germany between 2005 and 2021. The prognostic accuracy of ICH and ICH-GS scores were calculated by the area under the curve of the receiver operating characteristic curves. Analyzed outcomes were the in-hospital mortality, mortality at 6 months, in-hospital outcome, and outcome at 6 months.

RESULTS

Of 403 patients, 252 patients (62.5%) underwent surgical treatment and 151 patients (37.5%) conservative treatment. Both ICH and ICH-GS scores demonstrated good prognostic accuracy regarding both overall mortality and functional outcomes. In those patients presenting with severe cerebellar hemorrhages, ie, ICH score >3 and ICH-GS score >11, overall mortality was significantly lower in surgically treated patients. Mortality was significantly higher in those patients managed surgically who presented with ICH scores ≤3; in such patients, improved outcomes were noted when the hematoma was treated conservatively.

CONCLUSION

ICH and ICH scores are useful tools for prediction of survival and outcome in patients with cerebellar ICH. Surgical management may be beneficial for those who present with severe cerebellar ICH as reflected by ICH scores >3, while conservative management seems reasonable in patients with lower ICH scores.

Middle Meningeal Artery Embolization Minimizes Burdensome Recurrence Rates After Newly Diagnosed Chronic Subdural Hematoma Evacuation (MEMBRANE): study protocol for a randomized controlled trial

Background

Chronic subdural hematoma (cSDH) is the most common complication of mild traumatic brain injury demanding neurosurgery in high-income countries. If undetected and untreated, cSDH may increase intracranial pressure and cause neurological deficiencies. The first-line intervention of choice is burr hole trepanation and hematoma evacuation. However, any third patient may experience rebleeding, demanding craniotomy with excess morbidity. Adjunct endovascular embolization of the frontal and parietal branches of the middle meningeal artery (MMA) is a promising approach to avoid relapse and revision but was hitherto not studied in a randomized trial.

Methods

MEMBRANE is an investigator-initiated, single-center, randomized controlled trial. Male, female, and diverse patients older than 18 years scheduled for surgical evacuation of a first cSDH will be assigned in a 1:1 fashion by block randomization to the intervention (surgery plus endovascular MMA embolization) or the control group (surgery alone). The primary trial endpoint is cSDH recurrence within 3 months of follow-up after surgery. Secondary endpoints comprise neurological deficits assessed by the modified Rankin Scale (mRS) and recurrence- or intervention-associated complications during 3 months of follow-up. Assuming a risk difference of 20% of rebleeding and surgical revision, a power of 80%, and a drop-out rate of 10%, 154 patients will be enrolled onto this trial, employing an adaptive O’Brien-Fleming approach with a planned interim analysis halfway.

Discussion

The MEMBRANE trial will provide first clinical experimental evidence on the effectiveness of endovascular embolization of the MMA as an adjunct to surgery to reduce the risk of recurrence after the evacuation of cSDH.

Trial registration

German Clinical Trials Registry (Deutsches Register Klinischer Studien [DRKS]) DRKS00020465. Registered on 18 Nov 2021. ClinicalTrials.gov NCT05327933. Registered on 13 Apr 2022.

Health situation in Germany during the COVID-19 pandemic. Developments over time for selected indicators of GEDA 2019/2020 - An update

The spread of the coronavirus SARS-CoV-2 in 2020 and the containment measures associated therewith have changed many aspects of daily life. An impact on health even beyond infections itself is assumed as well. The health situation of the population in the first phase of the pandemic was thus analysed using data from the German Health Update (GEDA 2019/2020-EHIS). By continuing the survey, the analyses for 2020 are completed (n=26,507 participants), whereby the focus is now on the third phase of the pandemic (second wave of infection, gradual reintroduction of containment measures). The health indicators are presented on a monthly basis. As in the first phase of the pandemic, no pandemic-related changes were observed for tobacco smoking/ second-hand smoke exposure and for received/lack of/provided support. In contrast to the first phase of the pandemic, declines in utilisation of medical services and depressive symptoms are not observed in the third phase. The increase in body weight/body mass index after the first phase of the pandemic did not continue. The survey period allows for a comparison of the periods before and as of the pandemic situation. A decrease in the medical services utilisation and depressive symptoms as well as an increase in the body weight/body mass index is observed in the period from March 2020 to January 2021 compared to the pre-pandemic period from April 2019 to March 2020.

Angulation towards coronal convexity measure and catheter length indication improves the quality of ventricular catheter placement - a smartphone-assisted guidance technique

BACKGROUND

Accurate placement of a ventricular catheter is crucial to reduce the risk of shunt failure. In the randomized, prospective, multicenter GAVCA trial, which evaluated the quality of ventricular catheter placement, the subgroup of patients with detailed length marked ventricular catheters (dVC) reflected a difference in the primary endpoint of optimal VC placement in contrast to the subgroup of patients with simplified length marked ventricular catheters (sVC). Objective of this analysis is to compare the dVC-group with the sVC-group as well as the smartphone-assisted guidance technique (GA) with the standard freehand technique (F) for catheter placement.

METHODS

We performed a further analysis of the GAVCA trial in two steps: 1^st part) detailed length marked VCs (providing detailed distance from tip to base (3-13cm) in 0.5cm markings) compared to simplified length marked VCs with length indication at 5 cm and 10 cm from tip to base and 2^nd part) comparing the smartphone-assisted guidance technique vs. freehand technique in the dVC-group.

RESULTS

1^st part) Data of 137 patients (104 dVC patients vs. 33 sVC patients) was eligible for this analysis. Optimal VC placement was achieved in 72.1% of the dVC-group and 39.4% of the sVC-group (p=<0.001, odds ratio (OR) 3.9, 95% CI 1.7-9.3). 2^nd part) The 104 dVC patients underwent a subgroup analysis concerning the catheter placement using different techniques for catheter placement (54 guidance technique (GA) vs. 50 freehand technique (F). Optimal catheter placement was achieved in 81.5% of the GA group and 62.0% of the F group (p=0.03, odds ratio 2.7, 95% CI 1.1-6.8). All patients who underwent guidance technique ventricular catheter placement (GA) were successful on primary puncture while for 8.7% of patients in the freehand group (F), multiple attempts were necessary (p=0.03).

CONCLUSIONS

This analysis suggests the combination of a smartphone-assisted guidance technique (GA) and use of a detailed length marked ventricular catheter (dVC) to improve the rate of accurate ventricular catheter placement. Compared with freehand technique (F), patients' safety is increased by a reduction of unsuccessful ventricular catheter placement attempts.

Deep learning algorithm in detecting intracranial hemorrhages on emergency computed tomographies

BACKGROUND

Highly accurate detection of intracranial hemorrhages (ICH) on head computed tomography (HCT) scans can prove challenging at high-volume centers. This study aimed to determine the number of additional ICHs detected by an artificial intelligence (AI) algorithm and to evaluate reasons for erroneous results at a level I trauma center with teleradiology services.

METHODS

In a retrospective multi-center cohort study, consecutive emergency non-contrast HCT scans were analyzed by a commercially available ICH detection software (AIDOC, Tel Aviv, Israel). Discrepancies between AI analysis and initial radiology report (RR) were reviewed by a blinded neuroradiologist to determine the number of additional ICHs detected and evaluate reasons leading to errors.

RESULTS

4946 HCT (05/2020-09/2020) from 18 hospitals were included in the analysis. 205 reports (4.1%) were classified as hemorrhages by both radiology report and AI. Out of a total of 162 (3.3%) discrepant reports, 62 were confirmed as hemorrhages by the reference neuroradiologist. 33 ICHs were identified exclusively via RRs. The AI algorithm detected an additional 29 instances of ICH, missed 12.4% of ICH and overcalled 1.9%; RRs missed 10.9% of ICHs and overcalled 0.2%. Many of the ICHs missed by the AI algorithm were located in the subarachnoid space (42.4%) and under the calvaria (48.5%). 85% of ICHs missed by RRs occurred outside of regular working-hours. Calcifications (39.3%), beam-hardening artifacts (18%), tumors (15.7%), and blood vessels (7.9%) were the most common reasons for AI overcalls. ICH size, image quality, and primary examiner experience were not found to be significantly associated with likelihood of incorrect AI results.

CONCLUSION

Complementing human expertise with AI resulted in a 12.2% increase in ICH detection. The AI algorithm overcalled 1.9% HCT.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS-ID: DRKS00023593).

Clinical predictors of shunt response in the diagnosis and treatment of idiopathic normal pressure hydrocephalus: a systematic review and meta-analysis

Background

Positive shunt response (SR) remains the gold standard for diagnosing idiopathic normal pressure hydrocephalus (iNPH). However, multiple pathologies mimic iNPH symptoms, making it difficult to select patients who will respond to shunt surgery. Although presenting features, extended lumbar drainage (ELD), infusion test (IT), intracranial pressure monitoring (ICPM), and tap test (TT) have been used to predict SR, uncertainty remains over which diagnostic test to choose.

Objective

To conduct a systematic review and meta-analysis to identify clinical predictors of shunt responsiveness, evaluate their diagnostic effectiveness, and recommend the most effective diagnostic tests.

Methods

Embase, MEDLINE, Scopus, PubMed, Google Scholar, and JSTOR were searched for original studies investigating clinical predictors of SR in iNPH patients. Included studies were assessed using the QUADAS-2 tool, and eligible studies were evaluated using univariate and bivariate meta-analyses.

Results

Thirty-five studies were included. Nine studies discussed the diagnostic use of presenting clinical features, 8 studies ELD, 8 studies IT, 11 studies ICPM, and 6 studies TT. A meta-analysis of 21 eligible studies was conducted for TT, ELD, IT, and ICPM. ICPM yielded the highest diagnostic effectiveness, with diagnostic odds ratio (DOR) = 50.9 and area under curve (AUC) = 0.836. ELD yielded DOR = 27.70 and AUC = 0.753, IT had DOR = 5.70 and AUC = 0.729, and TT scored DOR = 3.86 and AUC = 0.711.

Conclusion

Intraparenchymal ICPM is statistically the most effective diagnostic test, followed by ELD, IT, and lastly TT. Due to the higher accessibility of TT and IT, they are recommended to be used first line, using a timed-up-and-go improvement ≥ 5.6 s or a Rout cut-off range between 13 and 16 mmHg, respectively. Patients who test negative should ideally be followed up with ICPM, using mean ICP wave amplitude \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\ge$$\end{document}≥ 4 mmHg, or 1- to 4-day ELD with an MMSE cut-off improvement \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\ge$$\end{document}≥ 3. Future research must use standardized methodologies for each diagnostic test and uniform criteria for SR to allow better comparison.

German Health Update (GEDA 2019/2020-EHIS) - Background and methodology

Between April 2019 and September 2020, 23,001 people aged 15 or over responded to questions about their health and living conditions for the German Health Update (GEDA 2019/2020-EHIS). The results are representative of the German resident population aged 15 or above. The response rate was 21.6%. The study used a questionnaire based on the third wave of the European Health Interview Survey (EHIS), which was carried out in all EU member states. EHIS consists of four modules on health status, health care provision, health determinants, and socioeconomic variables. The data are collected in a harmonised manner and therefore have a high degree of international comparability. They constitute an important source of information for European health policy and health reporting and are made available by the Statistical Office of the European Union (Eurostat). They also form the basis of the Federal Health Reporting undertaken in Germany. Data collection began in April 2019, just under a year before the beginning of the SARS-CoV-2 pandemic, and continued into its initial phase, as of March 2020. As such, data from the current GEDA wave can also be used to conduct research into the health impact of the SARS-CoV-2 pandemic.

Prospective observational cohort study on epidemiology, treatment and outcome of patients with traumatic brain injury (TBI) in German BG hospitals

OBJECTIVES

Since 2000/2001, no large-scale prospective studies addressing traumatic brain injury (TBI) epidemiology in Germany have been published. Our aim was to look for a possible shift in TBI epidemiology described in other European countries, to look for possible changes in TBI management and to identify predictors of 1-year outcome especially in patients with mild TBI.

DESIGN

Observational cohort study.

SETTING

All patients suffering from a TBI of any degree between 1 October 2014 and 30 September 2015, and who arrived in one of the seven participating BG hospitals within 24 hours after trauma, were included.

PARTICIPANTS

In total, 3514 patients were included.

OUTCOME MEASURES

Initial care, acute hospital care and rehabilitation were documented using standardised documentation forms. A standardised telephone interview was conducted 3 and 12 months after TBI in order to obtain information on outcome.

RESULTS

Peaks were identified in males in the early 20s and mid-50s, and in both sexes in the late 70s, with 25% of all patients aged 75 or older. A fall was the most frequent cause of TBI, followed by traffic accidents (especially bicyclists). The number of head CT scans increased, and the number of conventional X-rays of the skull decreased compared with 2000/2001. Besides, more patients were offered rehabilitation than before. Though most TBI were classified as mild, one-third of the patients participating in the telephone interview after 12 months still reported troubles attributed to TBI. Negative predictors in mild TBI were female gender, intracranial bleeding and Glasgow Coma Scale (GCS) 13/14.

CONCLUSION

The observed epidemiologic shift in TBI (ie, elderly patients, more falls, more bicyclists) calls for targeted preventive measures. The heterogeneity behind the diagnosis 'mild TBI' emphasises the need for defining subgroups not only based on GCS.

Corrigendum: Developments in the health situation in Germany during the initial stage of the COVID-19 pandemic for selected indicators of GEDA 2019/2020-EHIS

[This corrects the article on p. 3-20 in vol. 5.].

Step Back in Order to Go Forward: Willful Enlargement and Sandwich Closure Technique for Spinal Dura Repair after Several Unsuccessful Closure Attempts

A CSF leak is a common complication in spine surgery which is usually closed effectivly by suture and/or epidural patches. There is currently no algorithm to treat a recurrent CSF leak that fails to be closed initially. We describe the case of a recurrent cerebrospinal fluid leak that we have successfully treated using an inlay-onlay dural repair technique.

Developments in the health situation in Germany during the initial stage of the COVID-19 pandemic for selected indicators of GEDA 2019/2020-EHIS

SARS-CoV-2, the novel coronavirus, has posed major challenges in Germany in 2020. It is unclear whether the pandemic and containment measures will have an impact on the health of the population beyond the point of infection. The German Health Update (GEDA 2019/2020-EHIS) is a nationwide survey of the population aged 15 years and older (n=23,001) that was conducted between April 2019 and September 2020. The focus of the analysis was on indicators for which pandemic-related changes could be expected. Based on regression models, adjusted proportions and mean values were estimated as trends over time. Any differences in the values found for the time period of containment measures in spring 2020 and the reference period 2019 were statistically tested. Since the implementation of containment measures, both body weight and body mass index (BMI) have increased. The utilisation of general and specialist medical services decreased temporarily. The number of tobacco smokers during the observation period also decreased, yet without revealing a clear link to the pandemic situation. No differences were found in the general population for depressive symptoms and household assistance received and provided. During the period of containment measures, changes to the health situation beyond the occurrence of infections can be observed. However, a more differentiated explanation of these findings will require further analyses.

Gravitational shunt valves in hydrocephalus to challenge the sequelae of over-drainage

INTRODUCTION

In hydrocephalus treatment, ventriculo-peritoneal shunts (VPS) have become the most relevant therapy for seven decades among other treatment options. Due to the hydrostatic pressure in vertical position, CSF diversion is somehow non-physiological. The integration of gravitational valves in VPS was established to counteract the hydrostatic draining force and to approach a physiological condition of the cerebrospinal diverting system. Numerous clinical studies have shown that gravitational valves are able to reduce secondary complications of VPS treatment. It remains a challenge for the treating neurosurgeon to select the correct valve resistance based on individual anatomies and different etiologies of hydrocephalus as well as varying levels of activity of the patient.

AREAS COVERED

This review covers the development of gravitational shunt valves from historical, theoretical and clinical aspects for pediatric and adult etiologies of hydrocephalus. We discuss the role of gravitational shunt valves in preventing over-drainage issues and present the state-of-the-art literature. Furthermore, ongoing prospective trials are presented.

EXPERT OPINION

Counteracting the hydrostatic force by selecting the correct valve in a VPS system to achieve physiological balance in CSF diversion during vertical and horizontal body changes has become the current standard for hydrocephalus management. Gravitational shunt valves reliably address this need to minimize over-drainage events in the vertical position without affecting the CSF flow in the horizontal position. The results of ongoing prospective studies on the safety and efficacy of adjustable gravitational valves are still pending. Due to the complexity of the CSF flow, lifelong follow-up care for patients with VPS is critical.

Comparative investigation of different telemetric methods for measuring intracranial pressure: a prospective pilot study

OBJECTIVES

Measurement of intracranial pressure (ICP) plays an important role in long-term monitoring and neuro-intensive treatment of patients with a cerebral shunt. Currently, only two complete telemetric implants with different technical features are available worldwide. This prospective pilot study aims to examine patients who had both probes implanted at overlapping times for clinical reasons and represents the first in vivo comparison of both measurement methods.

MATERIALS AND METHODS

Patients with a primary subarachnoid hemorrhage or a spontaneous intracerebral hemorrhage with ventricular hemorrhage who had received a telemetric ICP probe (Raumedic® NEUROVENT®-P-tel) were included in the study. Conventional external ventricular drainages (EVD) and ventriculoperitoneal shunts with a telemetric ICP probe (Miethke Sensor Reservoir) were implanted in patients with hydrocephalus who required CSF (cerebrospinal fluid) drainage. Absolute ICP values from all systems were obtained. Due to the overlapping implantation time, parallel ICP measurements were performed via two devices simultaneously. ICP measurements via the sensor reservoir were repeated after 3 and 9 months. Differences between the absolute ICP values measured via the NEUROVENT®-P-tel probe, the Miethke sensor reservoir®, and the EVD were analyzed.

RESULTS

Seventeen patients were included in the present study between 2016 and 2018. 63% of all patients were male. In 11 patients the ICP measurements were followed up with both devices for 3 months. ICP measurements of the sensor reservoir showed corresponding trends in 9 cases compared to ICP measurement via the telemetry probe or EVD. Difference in absolute ICP values ranged between 14.5 mmHg and 0.0 mmHg. The average difference of the absolute ICP values in 8 cases was ≤ 3.5 mmHg.

CONCLUSION

ICP measurements with both systems continuously showed synchronous absolute ICP values, however absolute values of ICP measurement with the different systems did not match.

Ventriculoperitoneal Shunt Complications in the European Idiopathic Normal Pressure Hydrocephalus Multicenter Study

BACKGROUND

Ventriculoperitoneal shunt (VP-shunt) is the standard of treatment for idiopathic normal pressure hydrocephalus (iNPH). However, a thorough investigation of VP-shunt complications in this population is lacking.

OBJECTIVE

To present the analysis and the rates of complications progressively occurring during the first year after shunt surgery in the patients with iNPH included in the European multicenter (EU-iNPH) study.

METHODS

Patients (n = 142) were prospectively included in the EU-iNPH study by 13 institutions. All patients received a programmable VP-shunt. One hundred fifteen patients completed the 12-mo follow-up. Reexaminations were performed 1, 3, and 12 mo after surgery. Data regarding symptomatic over- or underdrainage, infections, malposition, subdural collections, and shunt surgery were collected and analyzed.

RESULTS

Thirty patients (26%) experienced symptoms due to shunt underdrainage. Symptomatic overdrainage was reported in 10 (9%). Shunt adjustments were made in 43 (37%). Shunt malposition was recognized as the primary cause of shunt malfunction in 8 (7%), while only 1 infection (0.9%) occurred. Subdural hematoma was diagnosed in 7 (6%) and was treated by increasing the opening pressure of the valve in 5 patients. Hygroma was diagnosed in 10 (9%), requiring surgery in 1 patient. Overall, 17 patients (15%) underwent 19 shunt surgeries.

CONCLUSION

The advances in valve technology, a careful opening pressure setting, and rigorous follow-up allow a significant reduction of complications, which can be usually managed nonsurgically within the first 3 to 6 mo.

Interventions to Increase the Reachability of Migrants in Germany With Health Interview Surveys: Mixed-Mode Feasibility Study

BACKGROUND

Germany is a popular destination for immigrants, and migration has increased in recent years. It is therefore important to collect reliable data on migrants' health. The Robert Koch Institute, Berlin, Germany, has launched the Improving Health Monitoring in Migrant Populations (IMIRA) project to sustainably integrate migrant populations into health monitoring in Germany.

OBJECTIVE

One of IMIRA's objectives is to implement a feasibility study (the IMIRA survey) that focuses on testing various interventions to increase the reachability of migrants with health interview surveys. Possible causes of nonresponse should be identified so as to increase participation in future surveys.

METHODS

The survey target populations were Turkish, Polish, Romanian, Syrian, and Croatian migrants, who represent the biggest migrant groups living in Germany. We used probability sampling, using data from the registration offices in 2 states (Berlin and Brandenburg); we randomly selected 9068 persons by nationality in 7 sample points. We applied age (3 categories: 18-44, 45-64, and ≥65 years) and sex strata. Modes and methods used to test their usability were culturally sensitive materials, online questionnaires, telephone interviews, personal contact, and personal interviews, using multilingual materials and interviewers. To evaluate the effectiveness of the interventions, we used an intervention group (group A) and a control group (group B). There were also focus groups with the interviewers to get more information about the participants' motivation. We used the European Health Interview Survey, with additional instruments on religious affiliation, experience of discrimination, and subjective social status. We evaluated results according to their final contact result (disposition code).

RESULTS

We collected data from January to May 2018 in Berlin and Brandenburg, Germany. The survey had an overall response rate of 15.88% (1190/7494). However, final disposition codes varied greatly with regard to citizenship. In addition to the quantitative results, interviewers reported in the focus groups a "feeling of connectedness" to the participants due to the multilingual interventions. The interviewers were particularly positive about the home visits, because "if you are standing at the front door, you will be let in for sure."

CONCLUSIONS

The IMIRA survey appraised the usability of mixed-mode or mixed-method approaches among migrant groups with a probability sample in 2 German states. When conducting the survey, we were confronted with issues regarding the translation of the questionnaire, as well as the validity of some instruments in the survey languages. A major result was that personal face-to-face contact was the most effective intervention to recruit our participants. We will implement the findings in the upcoming health monitoring study at the Robert Koch Institute.

Secondary deterioration in patients with normal pressure hydrocephalus after ventriculoperitoneal shunt placement: a proposed algorithm of treatment

Background

After ventriculoperitoneal shunt surgery for idiopathic normal pressure hydrocephalus (iNPH) with adjustable gravitational valves, a certain proportion of patients develop secondary clinical worsening after initial improvement of clinical symptoms. The aim of this study was to analyze this group of patients with secondary deterioration and to evaluate the performed shunt management.

Methods

For this investigation, we retrospectively reviewed our NPH registry for patients included between 1999 and 2013 with a decrease by a minimum of two points in the Kiefer score in the first year of follow up and an increase of two points in the Kiefer score between the second and the fifth year after shunt surgery (secondary deterioration). Then, we analyzed the patient’s shunt management (adapting the valve pressure setting, shuntography, valve replacement, catheter replacement, implant an adjustable gravitational unit). Additionally, we searched for risk factors for secondary deterioration.

Results

Out of 259 iNPH patients, 53 (20%) patients showed secondary deterioration on an average of 2.7 (2–4 years) years after shunt surgery. Fourteen (26%) patients with secondary deterioration improved after shunt or valve management and 58% remained without clinical benefit after management. We had a drop-out rate of 15% due to incomplete datasets. Our shunt management reduced the rate of secondary deterioration from 20 to 15%. On the basis of our findings, we developed an algorithm for shunt management. Risk factors for secondary deterioration are the age of the patient at the time of shunting, newly diagnosed neurodegenerative diseases, and overdrainage requiring adjusting the valve to higher-pressure levels.

Conclusion

Twenty percent of patients with iNPH were at risk for secondary clinical worsening about 3 years after shunt surgery. About one-fourth of these patients benefited for additional years from pressure level management and/or shunt valve revision. Our findings underline the need for long-term follow-ups and intensive shunt management to achieve a favorable long-term outcome for patients with iNPH and VPS.

Expression and activity of hyaluronidases HYAL-1, HYAL-2 and HYAL-3 in the human intervertebral disc

PURPOSE

Hyaluronic acid plays an essential role in water retention of the intervertebral disc (IVD) and thus provides flexibility and shock absorbance in the spine. Hyaluronic acid gets degraded by hyaluronidases (HYALs), and some of the resulting fragments were previously shown to induce an inflammatory and catabolic response in human IVD cells. However, no data currently exist on the expression and activity of HYALs in IVD health and disease.

METHODS

Gene expression, protein expression and activity of HYALs were determined in human IVD biopsies with different degrees of degeneration (n = 50 total). Furthermore, freshly isolated human IVD cells (n = 23 total) were stimulated with IL-1β, TNF-α or H₂O₂, followed by analysis of HYAL-1, HYAL-2 and HYAL-3 gene expression.

RESULTS

Gene expression of HYAL-1 and protein expression of HYAL-2 significantly increased in moderate/severe disc samples when compared to samples with no or low IVD degeneration. HYAL activity was not significantly increased due to high donor-donor variation, but seemed overall higher in the moderate/severe group. An inflammatory environment, as seen during IVD disease, did not affect HYAL-1, HYAL-2 or HYAL-3 expression, whereas exposure to oxidative stress (100 µM H₂O₂) upregulated HYAL-2 expression relative to untreated controls.

CONCLUSION

Although HYAL-1, HYAL-2 and HYAL-3 are all expressed in the IVD, HYAL-2 seems to have the highest pathophysiological relevance. Nonetheless, further studies will be needed to comprehensively elucidate its significance and to determine its potential as a therapeutic target. These slides can be retrieved under Electronic Supplementary Material.

GAVCA Study: Randomized, Multicenter Trial to Evaluate the Quality of Ventricular Catheter Placement with a Mobile Health Assisted Guidance Technique

BACKGROUND

Freehand ventricular catheter placement may represent limited accuracy for the surgeon's intent to achieve primary optimal catheter position.

OBJECTIVE

To investigate the accuracy of a ventricular catheter guide assisted by a simple mobile health application (mhealth app) in a multicenter, randomized, controlled, simple blinded study (GAVCA study).

METHODS

In total, 139 eligible patients were enrolled in 9 centers. Catheter placement was evaluated by 3 different components: number of ventricular cannulation attempts, a grading scale, and the anatomical position of the catheter tip. The primary endpoint was the rate of primary cannulation of grade I catheter position in the ipsilateral ventricle. The secondary endpoints were rate of intraventricular position of the catheter's perforations, early ventricular catheter failure, and complications.

RESULTS

The primary endpoint was reached in 70% of the guided group vs 56.5% (freehand group; odds ratio 1.79, 95% confidence interval 0.89-3.61). The primary successful puncture rate was 100% vs 91.3% (P = .012). Catheter perforations were located completely inside the ventricle in 81.4% (guided group) and 65.2% (freehand group; odds ratio 2.34, 95% confidence interval 1.07-5.1). No differences occurred in early ventricular catheter failure, complication rate, duration of surgery, or hospital stay.

CONCLUSION

The guided ventricular catheter application proved to be a safe and simple method. The primary endpoint revealed a nonsignificant improvement of optimal catheter placement among the groups. Long-term follow-up is necessary in order to evaluate differences in catheter survival among shunted patients.

An interdisciplinary approach to the treatment of a complex infraclinoidal internal carotid artery aneurysm

We present the case of a 49-year-old woman with sudden onset of severe headaches and a ruptured aneurysm located inside the fenestration of the infraclinoid part of the internal carotid artery in the segments C4 and C5 distal to the origin of the ophthalmic artery. An interdisciplinary approach enabled the successful treatment of the aneurysm by wrapping and stent-assisted coiling. We discuss this rare congenital anomaly of a fenestrated internal carotid artery together with the 12 other cases published worldwide.

Efficacy and safety of programmable compared with fixed anti-siphon devices for treating idiopathic normal-pressure hydrocephalus (iNPH) in adults - SYGRAVA: study protocol for a randomized trial

BACKGROUND

Idiopathic normal-pressure hydrocephalus (iNPH) is a distinct form of dementia, characterized by gait ataxia, cognitive impairment and urinary incontinence. In contrast to all other causes of dementia (e.g., Alzheimer-type and others), ventriculoperitoneal (VP) shunt surgery may offer a curative treatment option to patients. While being a rather low-risk type of surgery, it may cause significant over- or underdrainage complications (e.g., headaches, dizziness, vomiting, intracerebral bleeding, etc.) during posture change. Anti-siphon devices (ASDs) are a group of technically different additional valves used in shunt surgery. They are designed to maintain intraventricular pressure within a normal physiological range regardless of patient position. Fixed ASDs proved to substantially lower the rate of overdrainage complications. No significant differences, however, were noted regarding underdrainage complications. Technical successors of fixed ASDs are programmable ASDs. The aim of this study is to evaluate whether programmable ASDs compared to fixed ASDs are able to avoid both over- and underdrainage complications.

METHODS/DESIGN

In this investigator-initiated, multicenter randomized trial, 306 patients are planned to be recruited. Male and female patients aged ≥18 years with iNPH who are eligible for VP shunt surgery and meet all other entry criteria can participate. Patients will be randomized in a balanced 1: 1 fashion to a VP shunt with a programmable valve either supplemented with a fixed ASD, or a programmable ASD. Patients will be followed-up 3, 6 and, on an optional basis, 12 months after surgery. The primary outcome measure is the cumulative incidence of over- or underdrainage 6 months post surgery, as defined by clinical and imaging parameters.

DISCUSSION

SYGRAVA is the first randomized trial to determine whether programmable ASDs reduce complications of drainage compared to fixed ASDs in patients with iNPH. The results of this study may contribute to health-technology assessment of different valve systems used for VP-shunt surgery, and determination of the future standard of care.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number: ISRCTN13838310 . Registered on 10 November 2016.

Affinities of human NMDA receptor autoantibodies: implications for disease mechanisms and clinical diagnostics

Anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis is a common autoimmune encephalitis presenting with psychosis, dyskinesias, autonomic dysfunction and seizures. The underlying autoantibodies against the NR1 subunit are directly pathogenic by disrupting synaptic NMDAR currents. However, antibody titers correlate only partially with the clinical outcome, suggesting the relevance of other factors such as antibody affinity. We thus determined the binding curves of human monoclonal autoantibodies and patients’ cerebrospinal fluid (CSF) against NR1-expressing HEK293 cells using flow cytometry. Antibody affinity was highly variable with binding constants (half-maximal concentration, c₅₀) ranging from 1 to 74 µg/ml for monoclonal antibodies. Comparing values of individual monoclonal antibodies with human CSF samples suggested that the CSF signal is predominantly represented by higher-affinity antibodies, potentially in a concentration range of NR1 antibodies between 0.1 and 5 µg/ml, roughly reflecting 1–10% of total CSF IgG in NMDAR encephalitis. Binding curves further depended on the CSF composition which must be considered when interpreting established clinical routine assays. Normalization of measurements using reference samples allowed high reproducibility. Accurate and reproducible measurement of NR1 antibody binding suggested that biophysical properties of the antibody might contribute to disease severity. Normalization of the data can be an elegant way to allow comparable inter-laboratory quantification of CSF NR1 antibody titers in autoimmune encephalitis patients, a prerequisite for use as surrogate markers in clinical trials. Based on our calculations, low-affinity antibodies can easily remain undetected in routine cell-based assays, indicating that their relation to clinical symptoms should be analyzed in future studies.

Ad hoc surveys at the Robert Koch Institute

The Robert Koch Institute (RKI) regularly conducts nationally representative cross-sectional studies (KiGGS, DEGS and GEDA) as part of the nationwide health monitoring system. In addition to these health surveys, data is collected in telephone interviews either on specific thematic fields (such as diabetes) or specific groups (such as medical staff) that were not or only insufficiently covered by the larger health surveys. As they are flexible and fast, ad hoc surveys conducted via telephone interviews can respond to specific epidemiological and health political questions. This article describes the procedures applied in ad hoc telephone interview surveys, which were newly introduced as a standardised method in 2017 and are applied by the Laboratory for Health Surveys at the RKI. The article presents the stages of project management such as concept development, establishment of a concept for data protection, questionnaire development, pre-test and field phase, calculation of weighting factors and provision of the final data set. The aim is to describe the process and shed light on the standardised procedures, the reported quality indicators and the breadth of possible scenarios of application.

First results from the study 'Disease knowledge and information needs - Diabetes mellitus (2017)'

Very little research has been undertaken into what people in Germany know about diabetes, the information they may require about the condition, where they look for such information and how they rate the information currently available. In 2017, the Robert Koch Institute (RKI) carried out a nationwide telephone survey aimed at answering these questions. The study entitled 'Disease knowledge and information needs - Diabetes mellitus (2017)' focused on people aged at least 18 years. A total of 2,327 people without diabetes and 1,479 people with diagnosed diabetes were interviewed for the study. First results show that 56.7% of people without diabetes and 92.8% of those with diabetes rate their knowledge about the condition as 'very good' or 'good'. People without diabetes were found to have the strongest need for information in terms of 'lifestyle changes, health promotion and disease prevention', whereas respondents with diabetes stressed the strongest need for information about 'treatment and therapy'. Almost a third of respondents without diabetes have actively sought information about diabetes at least once, mostly via print media. Patients with diabetes stated that their general practitioner was their most frequent source of information about the condition. In both groups, about half of respondents reported that they found it difficult to judge the trustworthiness of the information published in the media about diabetes. The results of the study form part of the German National Diabetes Surveillance, which is coordinated by the RKI. The data are also intended to be used by the Federal Centre for Health Education to develop a strategy to improve the information provided about diabetes.

Sedation of Patients with Acute Aneurysmal Subarachnoid Hemorrhage with Ketamine Is Safe and Might Influence the Occurrence of Cerebral Infarctions Associated with Delayed Cerebral Ischemia

BACKGROUND

Ketamine has neuroprotective characteristics as well as beneficial cardiocirculatory properties and may thus reduce vasopressor consumption. In contrast, sedation with ketamine (like any other sedative drug) has side effects. This study assesses the influence of ketamine on intracranial pressure (ICP), on the consumption of vasopressors in induced hypertension therapy, and on the occurrence of delayed cerebral ischemia (DCI)-associated cerebral infarctions, with particular focus on the complications of sedation in patients with aneurysmal subarachnoid hemorrhage (SAH).

METHODS

This is a retrospective, observational study. Sixty-five patients with SAH who underwent a period of sedation were included. The clinical course variables (Richmond Agitation and Sedation scale score, ICP values, consumption of vasopressors, complications of sedation, outcome, and other clinical parameters) were analyzed. Cranial computed tomography results were analyzed.

RESULTS

Forty-one patients underwent sedation including ketamine (63.1%). Ketamine decreased the ICP in 92.7% of the cases. Vasopressors was reduced in 53.6%. DCI-associated cerebral infarctions occurred significantly less often in the patient cohort being treated with sedation including ketamine (7.3% vs. 25% in the nonketamine group; P = 0.04). The rate of major complications was not higher in the ketamine group. Outcome was not different regarding the groups if they were sedated with or without ketamine.

CONCLUSIONS

Ketamine decreases the ICP and is not associated with a higher rate of complications. The rate of DCI-associated cerebral infarctions was lower in the ketamine group. Ketamine administration led to a reduction of vasopressors used for induced hypertension.

Nationwide Incidence of Normal Pressure Hydrocephalus (NPH) Assessed by Insurance Claim Data in Germany

BACKGROUND

The purpose of this study is to investigate the epidemiology of the idiopathic normal pressure hydrocephalus (iNPH) in Germany.

METHODS

The database of the nationwide Barmer Health Insurance was queried for specific combinations of corresponding International Classification of Diseases, Ninth Revision (ICD-9) codes and OPS codes (German modification of the ICPM and official classification of surgical procedures) in order to assess the number of patients treated for iNPH and the number surgical procedures associated with the disease in a 10 years period between 2003 and 2012.

RESULTS

Between 2003 and 2012, the incidence of iNPH increased from zero to 1.36/100.000/year.

CONCLUSION

This is the first population-based epidemiologic study on iNPH in Germany covering a ten year period.

The dilemma of complicated shunt valves: How to identify patients with posthemorrhagic hydrocephalus after aneurysmatic subarachnoid hemorrhage who will benefit from a simple valve?

Background:

Sophisticated shunt valves provide the possibility of pressure adjustment and antisiphon control but have a higher probability of valve dysfunction especially in a posthemorrhagic setting. The aim of the present study is to analyze the clinical outcome of patients with shunt dependent posthemorrhagic hydrocephalus after aneurysmatic subarachnoid hemorrhage (SAH) in order to identify patients who would benefit from a simple differential pressure valve.

Methods:

From 2000 to 2013, 547 patients with aneurysmatic SAH were treated at our institution, 114 underwent ventricular shunt placement (21.1%). 47 patients with available pre- and post-operative computed tomography scans, and an available follow-up of minimum 6 months were included. In order to measure the survival time which a nonprogrammable differential pressure valve would have had in an individual patient we defined the initial equalized shunt survival time (IESS). IESS is the time until surgical revisions of fixed differential pressure or flow-regulated valves for the treatment of over- or under-drainage as well as re-programming of adjustable valves due to over- or under-drainage.

Results:

Twenty patients were treated with fixed differential pressure valves, 15 patients were treated with flow-regulated valves, and 12 underwent ventriculoperitoneal (VP) shunt placement with differential pressure valves assisted by a gravitational unit. Patients who reacted with remarkable changes of the ventricular width after the insertion of external ventricular drainage (EVD), before shunt placement, showed a significantly longer IESS.

Conclusions:

Decline of the ventricular width after EVD placement was a predictor for successful VP shunt therapy in the later course of disease. Possibly, this could allow identifying patients who benefit from a simple differential pressure valve or a flow-regulated valve, and thus could possibly avoid valve-associated complications of a programmable valve in the later course of disease.

Open Traumatic Brain Injury Is a Strong Predictor for Aseptic Bone Necrosis after Cranioplasty Surgery: A Retrospective Analysis of 219 Patients

OBJECTIVE

To investigate whether independent predictors of complications after cranioplasty are identifiable.

METHODS

Parameters that could predict the occurrence of complications were analyzed retrospectively. The end point of the study was the explantation of the bone flap.

RESULTS

A total of 219 patients with a mean age of 42.8 years (standard deviation: 17.89) were included. History of trauma and especially open traumatic brain injury (TBI) were associated with a higher complication rate (p = 0.01 and p = 0.02, respectively). Multivariate testing showed that fragmented bone flap resulted in a more frequent occurrence of bone flap necrosis (p = 0.014). The risk of complications following cranioplasty was higher if a ventriculoperitoneal (VP) shunt was placed at the same time (p = 0.01). Longer duration of the cranioplasty procedure was significantly associated with a higher postoperative complication rate (p = 0.001). Subsequent rehabilitation is more frequent if patients develop a complication.

CONCLUSIONS

To avoid complications after cranial vault reconstruction, indications for simultaneous VP shunt implantation should be carefully evaluated. The implantation of traumatically fragmented bone flaps should be avoided. Patients after open TBI should either primarily be treated with an allogenic graft or they should be carefully followed up because they are prone to develop aseptic necrosis.

Outcome of modern shunt therapy in patients with idiopathic normal pressure hydrocephalus 6 years postoperatively

Object

Shunt therapy in idiopathic normal pressure hydrocephalus (iNPH) can improve symptoms in 84% of patients 1 year postoperatively. Therefore, implantation of a ventriculoperitoneal shunt (VPS) prevents or at least prolongs the time during which patients are not dependent on care from others because of gait disorder or dementia. In this study, the medium-term results of modern shunt therapy were evaluated.

Methods

The authors retrospectively studied outcome in iNPH patients in whom VPSs were implanted. At yearly follow-up examinations over at least 6 years, clinical symptoms were recorded according to the NPH recovery rate (NPH-RR): (preoperative Kiefer Scale [KS] score − postoperative KS score)/(preoperative KS score × 10). Time and cause of death over this period were also analyzed.

Results

Among the 147 patients treated for iNPH in the period between 1997 and 2006, 69 had died at the time of the authors' survey. Sixty-one patients reached the 6-year examination. The median age was 64 years (range 33–83 years) at the time of VPS implantation and 73 years (range 41–91 years) at the time of this study. Six years after shunt implantation, the median KS score was significantly lower than the preoperative score (4.3 vs 8.1 points). Fifty-nine percent of 61 patients had an excellent outcome, 15% had satisfactory benefit, and 26% had unsatisfactory results 6 years postoperatively. Three of the 147 patients who underwent implantation of a VPS died of cerebral diseases 4–10 years postoperatively.

Conclusions

Implantation of a VPS is a safe procedure and can improve symptoms in 74% of patients with iNPH in the longer term.

Predictors of subsequent overdrainage and clinical outcomes after ventriculoperitoneal shunting for idiopathic normal pressure hydrocephalus

BACKGROUND

Little is known about variables associated with overdrainage complications and neurofunctional and health-related quality of life outcomes in idiopathic normal-pressure hydrocephalus (iNPH) patients after shunt surgery.

OBJECTIVE

To identify candidate demographic and disease-specific predictors of overdrainage and patient-related outcomes, allowing for more personalized care of patients with iNPH.

METHODS

This was a secondary analysis of the dataset of the SVASONA study, a multicenter randomized trial comparing gravitational and conventional gravitational valves for treating iNPH. We evaluated the association between baseline items and the incidence of overdrainage, using different endpoint definitions.

RESULTS

We identified only a few variables associated with a possible increased risk of overdrainage. Apart from using conventional rather than gravitational valves, longer duration of surgery and female sex were associated with a higher risk of clinical signs and symptoms suggestive of overdrainage (hazard ratio: 1.02, 95% confidence interval: 1.01-1.04 and 1.84, 95% confidence interval: 0.81-4.16). The occurrence of clinical symptoms of overdrainage, and the need for exchanging a programmable by a gravitational valve may adversely affect disease-specific outcomes like the Kiefer score.

CONCLUSION

Few, if any, baseline and treatment characteristics may be helpful in estimating the individual risk of complications and clinical outcomes after shunt surgery for iNPH. Patients should be informed that longer surgery for any reason may increase the risk of later overdrainage. Also, women should be counseled about a sex-associated increased risk of the development of clinical symptoms of overdrainage, although the latter cannot be distinguished from a generally higher prevalence of headaches in the female population.

Indications for valve-pressure adjustments of gravitational assisted valves in patients with idiopathic normal pressure hydrocephalus

Background:

Modern ventriculoperitoneal shunts (VPS) are programmable, which enables clinicians to adjust valve-pressure according to their patients’ individual needs. The aim of this retrospective analysis is to evaluate indications for valve-pressure adjustments in idiopathic normal pressure hydrocephalus (iNPH).

Methods:

Patients operated between 2004 and 2011 diagnosed with iNPH were included. Kiefer-Scale was used to classify each patient. Follow-up exams were conducted 3, 6, and 12 months after shunt implantation and yearly thereafter. Initial valve-pressure was 100 or 70 mmH₂O. Planned reductions of the valve-pressure to 70 and 50 mmH₂O, respectively, were carried out and reactive adjustment of the valve-pressure to avoid over- and under-drainage were indicated.

Results:

A total of 52 patients were provided with a Medos-Hakim valve^Codman® with a Miethke shunt-assistant^Aesculap® and 111 patients with a Miethke-proGAV^Aesculap®. 180 reductions of the valve-pressure took place (65% reactive, 35% planned). Most patients (89%) needed one or two adjustments of their valve-pressures for optimal results. In 41%, an improvement of the symptoms was observed. Gait disorder was improved most often after valve-pressure adjustments (32%). 18 times an elevation of valve-pressure was necessary because of headaches, vertigo, or the development of subdural hygroma. Optimal valve-pressure for most patients was around 50 mmH₂O (36%).

Conclusion:

The goal of shunt therapy in iNPH should usually be valve-pressure settings between 30 and 70 mmH₂O. Reactive adjustments of the valve-pressure are useful for therapy of over- and underdrainage symptoms. Planned reductions of the valve opening pressure are effective even if postoperative results are already satisfactory.

Acute decompensation of noncommunicating hydrocephalus caused by dilated Virchow-Robin spaces type III in a woman treated by endoscopic third ventriculostomy: a case report and review of the literature

BACKGROUND AND IMPORTANCE

Even though dilated Virchow-Robin spaces (VRS) are a very rare entity, they can compel the clinician to start immediate intervention in the case of acute onset of symptoms. To allow a well-balanced management decision, we compiled a summary of all cases published in the literature and discuss the different methods and indications for neurosurgical intervention in relation to dilated VRS.

CLINICAL PRESENTATION

We report a case of a 43-year-old female patient who came to admission after syncope with a history of unspecific neck pain, fatigue, diplopia, and dizziness. Dilated VRS type III causing a noncommunicating hydrocephalus were found to be responsible. Although the patient was initially awake, within 72 hours after admission, a deterioration of consciousness and repeated vomiting were observed. The patient underwent an urgent endoscopic third ventriculostomy (ETV) and was discharged in a good condition.

CONCLUSION

To the best of our knowledge, the case presented here is the first case of acute decompensation of a noncommunicating hydrocephalus caused by dilated VRS. Neurosurgical intervention is required in cases of noncommunicating hydrocephalus caused by giant tumefactive VRS. The treatment options are mono- or biventricular shunt surgery or ETV. Because ETV provides the possibility of cyst fenestration and membrane sampling, it appears to be the most advantageous treatment option.

Safety and efficacy of gravitational shunt valves in patients with idiopathic normal pressure hydrocephalus: a pragmatic, randomised, open label, multicentre trial (SVASONA)

OBJECTIVES

To investigate whether gravitational valves reduce the risk of overdrainage complications compared with programmable valves in ventriculoperitoneal (VP) shunt surgery for idiopathic normal pressure hydrocephalus (iNPH).

BACKGROUND

Patients with iNPH may benefit from VP shunting but are prone to overdrainage complications during posture changes. Gravitational valves with tantalum balls are considered to reduce the risk of overdrainage but their clinical effectiveness is unclear.

METHODS

We conducted a pragmatic, randomised, multicentre trial comparing gravitational with non-gravitational programmable valves in patients with iNPH eligible for VP shunting. The primary endpoint was any clinical or radiological sign (headache, nausea, vomiting, subdural effusion or slit ventricle) of overdrainage 6 months after randomisation. We also assessed disease specific instruments (Black and Kiefer Scale) and Physical and Mental Component Scores of the Short Form 12 (SF-12) generic health questionnaire.

RESULTS

We enrolled 145 patients (mean (SD) age 71.9 (6.9) years), 137 of whom were available for endpoint analysis. After 6 months, 29 patients in the standard and five patients in the gravitational shunt group developed overdrainage (risk difference -36%, 95% CI -49% to -23%; p<0.001). This difference exceeded predetermined stopping rules and resulted in premature discontinuation of patient recruitment. Disease specific outcome scales did not differ between the groups although there was a significant advantage of the gravitational device in the SF-12 Mental Component Scores at the 6 and 12 month visits.

CONCLUSIONS

Implanting a gravitational rather than another type of valve will avoid one additional overdrainage complication in about every third patient undergoing VP shunting for iNPH.

Spinal manifestation of hydatid disease: a case series of 36 patients

OBJECTIVE

Vertebral hydatid cysts are found in <1% of all cases of hydatidosis. The pathology has an infiltrative malignant nature, affecting the vertebral body with possible extension in the epidural space. This pathomechnism is associated with a high rate of morbidity, mortality, and relapse. Decompressive surgery combined with antihelminthic therapy is recommended to eradicate the disease and prevent recurrence.

METHODS

Between 1990 and 2007, 36 patients with a mean age of 31 years were diagnosed as having spinal hydatid disease and underwent surgery on several occasions for multiple recurrences. Combined chemotherapy with albendazole also was given.

RESULTS

Initial surgery and chemotherapy steadied clinical progression and functional deterioration, but with a recurrence rate of 89% and an average time to disease recurrence of 2.5 years, did not improve the known malignant course of disease in comparison to the literature.

CONCLUSION

The devastating and malignant course of this disease, which affects mostly young patients, demands continuous development of preventive care in endemic regions, the early detection and screening of the diseased patients, and eventually the advancement of the combined medical and surgical treatment.

Ballistics for neurosurgeons: Effects of firearms of customized cranioplasty implants

Introduction:

There are about 33,000 deaths caused by gunshot wounds in the USA each year. Probably half of these deaths result from head wounds. Among US Army soldiers, 17% of all ballistic injuries are head wounds. This means that, even in those protected by ballistic helmets, gunshot injuries to the head represent a danger. The aim of this study was to examine the effects of shelling of computer-aided designed (CAD) cranioplasty implants made of two different materials.

Methods:

An experimental model was developed in an indoor gun range. CAD cranioplasties with a material thickness of 2-6 mm, made of titanium or PEEK-OPTIMA^® were fixed in a watermelon and shot at with a .222 Remington rifle at a distance of 30 m distance, a .30-06 Springfield rifle at a distance of 30 m, a Luger 9 mm pistol at a distance of 8 m, or a .375 Magnum revolver at a distance of 8 m. The CAD cranioplasties were subsequently inspected for ballistic effects by a neurosurgeon.

Results:

Titanium CAD cranioplasty implants resisted shots from the 9 mm Luger pistol and were penetrated by both the .222 Remington and the .30-06 Springfield rifle. Shooting with the .357 Magnum revolver resulted in the titanium implant bursting. PEEK-OPTIMA^® implants did not resist bullets shot from any weapon. The implants burst on shooting with the 9 mm Luger pistol, the .222 Remington, the .30-06 Springfield rifle, and the .357 Magnum revolver.

Conclusions:

Titanium CAD cranioplasty implants may offer protection from ballistic injuries caused by small caliber weapons fired at short distances. This could provide a life-saving advantage in civilian as well as military combat situations.

On the method of a randomised comparison of programmable valves with and without gravitational units: the SVASONA study

OBJECTIVE

The supremacy of low-pressure valves (LPV) in the therapy of patients with idiopathic normal pressure hydrocephalus (iNPH) has been proven by the Dutch NPH study. The downside of LPVs is the high rate of overdrainage complications. In the meantime gravitational units have been developed with the objective of minimising overdrainage complications. Do these gravitational units allow the same favourable outcomes as in the Dutch NPH study without overdrainage complications? The goal of this prospective randomised controlled multicentre trial is to compare the rate of overdrainage complications after shunt surgery with programmable valves with or without a gravitational unit.

METHOD

Patients suspected with iNPH with gait ataxia and one or two other symptoms of Hakim's triad and enlarged ventricles on CT or MRI underwent a cerebrospinal fluid (CSF) infusion test, CSF tap test and/or continuous ICP measurement in seven experienced centres. If iNPH was diagnosed the patients were randomised to receive a ventriculoperitoneal shunt with a programmable valve with or without a gravitational unit. The patients were followed up for 3, 6 and 12 months after surgery. The primary hypothesis of the study was that programmable valves with gravitational units will reduce the rate of overdrainage from 25% to 10%. The outcome measured by iNPH-specific outcome scales (Kiefer score, Black grading scale) and the generic quality of life (short form 12, SF12) was defined as the secondary endpoint. To detect the hypothesised difference in the incidence of overdrainage with a type I error of 5% and a type II error of 20%, correcting for multiple testing and an anticipated drop-out rate of 10%, we planned to enrol 250 patients. To ensure safety and efficacy we performed a planned interim analysis halfway.

RESULTS

The study design has been found to be effective with regard to the primary hypothesis.

CONCLUSION

The design of the SVASONA study was developed to be able to confirm the primary hypothesis. Thus, the method of the study should solve the dilemma of the Dutch NPH study by the randomised comparison of LPVs with and without gravitational units.

Case study of relevant pressures for an implanted hydrocephalus valve in everyday life

Hydrocephalus patients with increased intracranial pressure are generally treated by draining cerebrospinal fluid (CSF) into the abdomen through an implanted shunt with a passive differential pressure valve. To perfectly adapt the valve's opening pressure to the patient's need, more information on the acutal pressure across the valve in everyday life actions like walking, eating, sleeping etc. is necessary.

Polyetheretherketone (PEEK) Spacers for Anterior Cervical Fusion: A Retrospective Comparative Effectiveness Clinical Trial

Background:

Anterior cervical decompression and fusion (ACDF) is the standard surgical treatment for radiculopathy and myelopathy. Polyetheretherketone (PEEK) has an elasticity similar to bone and thus appears well suited for use as the implant in ACDF procedures. The aim of this study is to examine the clinical and radiographic outcome of patients treated with standing alone PEEK spacers without bone morphogenic protein (BMP) or plating and to examine the influence of the different design of the two spacers on the rate of subsidence and dislocation.

Methods:

This retrospective comparative study reviewed 335 patients treated by ACDF in a specialized urban hospital for radiculopathy or myelopathy due to degenerative pathologies. The Intromed PEEK spacer was used in 181 patients from 3/2002 to 11/2004, and the AMT SHELL spacer was implanted in 154 patients from 4/2004 to 12/2007. The follow-up rate was 100% at three months post-op and 82.7% (277 patients) at one year. The patients were assessed with the Japanese Orthopedic Association (JOA) questionnaire and radiographically.

Results:

At the one-year follow-up there were 118/277 patients with an excellent clinical outcome on the JOA, 112/277 with a good outcome, 20/277 with a fair outcome, and 27/277 with a poor outcome. Subsidence was observed in 13.3% of patients with the Intromed spacer vs 8.4% of the patients with the AMT SHELL. Dislocation of the spacer was observed in 10 of the 181 patients with Intromed spacers but in none of the 154 patients with Shell spacers.

Conclusion:

The study demonstrates that ACDF with standing alone PEEK cages leads to excellent and good clinical outcomes. The differences we observed in the subsidence rate between the two spacers were not significant and cannot be related to a single design feature of the spacers.

Minimally invasive spinal surgery using nucleoplasty and the Dekompressor tool: a comparison of two methods in a one year follow-up

OBJECT

The Disc Dekompressor and Nucleoplasty are 2 different, minimally invasive, percutaneous methods in the therapy for chronic discogenic low back pain. The aim of this study is to compare the effectiveness of both methods concerning the outcome one year after surgery.

METHODS

We included patients with MRI-proven disc protrusion suffering from low back pain and/or radiating pain in the lower extremities. The pain perception of the patients was documented using the visual analogue pain scale (VAS). Furthermore, the patients were queried about analgesic consumption, disability in daily life and ability to work. Percutaneous minimally invasive nucleotomy using the Nucleoplasty or the Disc Dekompressor was carried out under fluoroscopic and CT-guidance. We carried out a follow-up examination at 6 and 12 months after the operation.

RESULTS

From April 2005 to November 2007 a total of 126 patients underwent percutaneous minimally invasive nucleotomy using Nucleoplasty (April 2005 - December 2006) or the Disk Dekompressor (February 2006 - November 2007) and were followed up after 6 and 12 months. In the Nucleoplasty group the mean age of the 27 females (39%) and 42 males (61%) was 42 years (range: 18-74). In the Disc Dekompressor group the mean age of the 22 females (39%) and 35 males (61%) was 44 years (range: 16-76). The mean duration of symptoms in the Nucleoplasty group was 30.5 months (range: 1-120), and in the Disc Dekompressor group 16.3 months (range: 1-72). Statistically significant postoperative improvement concerning the VAS score was evident in both groups. Whereas the VAS score slightly increased in the Nucleoplasty group comparing the early postoperative score and the score after 12 months, the VAS score stayed on a low level in the Disc Dekompressor group. A statistically significant reduction in analgesic consumption, disability and occupational incapacitation was observed in the Nuceloplasty group and the Disc Dekompressor group.

CONCLUSIONS

Both Nucleoplasty and Disc Dekompressor are effective therapies for chronic, discogenic back pain. Regardless of the different mechanism no significant differences in the outcomes were found. Both techniques result in significant reductions in levels of disability and incapacity for work as well as decreased analgesic consumption.