PURPOSE:To evaluate the effectiveness and safety of percutaneous vesselplasty in pathological vertebral fractures of the thoracolumbar spine in selected tumor patients.MATERIALS AND METHODS:Eleven pathological vertebral fractures in nine patients were treated with vesselplasty (Vessel-X®, MAXXSPINE). Nine of eleven vertebras (81.8 %) had major posterior wall deficiency (> 30 %). Clinical and radiological (CT) measures were obtained before and 3 months after the procedure.RESULTS:The mean VAS improved significantly from preoperative to postoperative (6.9 ± 2.2 to 3.7 ± 2.3; p < 0.05), as did the ODI (59.7 %± 19.2 % to 40.3 %± 24.0 %; p < 0.05). The physical component summary of the SF-36 was significantly improved by the operation (19.2 ± 8.0 to 31.0 ± 16.5; p < 0.05). Symptomatic cement leakage or other operation-associated complications were not observed. Three patients were primarily treated with concomitant minimally invasive stabilization via fixateur interne. One patient had to undergo minimally invasive stabilization via fixateur interne 4 months after vesselplasty due to further collapse of the treated vertebral body.CONCLUSION:From these preliminary results, vesselplasty appears to be a treatment option worth considering in pathological vertebral fractures, even in the case of posterior wall deficiency. Selected tumor patients might benefit from vesselplasty as a minimally invasive procedure for stabilization of the fractured vertebra, pain control, and improvement in body function and quality of life. Long-term prospective studies with a larger sample size are required to validate these results.

Object: In single patients with a cerebral aneurysm an external ventricular drain (EVD), an intracranial pressure (ICP) gauge or a combined EVD and ICP gauge placement is necessary after coil embolization and initiation of postprocedural anticoagulation. The aim of this study was to examine the hemorrhage rates of drain placement within 48 h after aneurysm coiling and under anticoagulation or antiplatelet therapy.Methods: We retrospectively analyzed hemorrhage rates of EVD, ICP gauge or combined EVD and ICP gauge placement in 27 patients within 48 h after coil embolization under different anticoagulation or antiplatelet schemes (heparin, acetylsalicylic acid, clopidogrel). In patients with continuous heparin via perfusor the application was stopped periprocedurally. The results were compared to literature.Results: Four hemorrhages (14.8%) were observed. Three hemorrhages were petechial and one was by definition a larger hemorrhage with 8 mm x 10 mm in diameter.Conclusions: EVD, ICP gauge or combined EVD and ICP gauge placements within 48 h after cerebral aneurysm coiling and under different anticoagulation or antiplatelet regimens seem to have no increased risk of hemorrhages compared to literature. (C) 2013 Elsevier B.V. All rights reserved.

OBJECTIVE:We present a novel technique for minimally invasive revision of a cervical isthmic screw via two 18-mm transmuscular tubular accesses.METHODS:A 55 year old male with combined anterior and posterior instrumentation after corpectomy of C3 to C4 complained of persistent neck pain and reduced head mobility in the follow-up examination. Isthmic screws had been placed in C2 and pedicle screws in C5. The system used is a versatile modular screw-rod system for the fixation of the occipito-cervico-thoracic spine. The patient's complaints were attributed to an inappropriately placed C2 isthmus screw. The screw was approximately 3 mm too long and perforated the C1-C2 facet joint on the left side. We replaced the screw by a shorter one through a minimally invasive transmuscular tubular approach.RESULTS:The transmuscular tubular access offered an adequate exposure of the screw head. The special features of the versatile modular fixation device allowed for screw easing, removal, replacement, and tightening through the tube. The symptoms of the patient resolved completely. Intraoperative blood loss and postoperative approach-associated pain were negligible.CONCLUSION:We conclude that in case of dorsal cervical fixation with a versatile modular screw-rod system, a minimally invasive transmuscular approach for revision of an isthmic screw may be a good alternative to open surgery.

This patient presented with low-back pain and unilateral leftsided sciatica, which were attributed to a spondylolisthesis at L4–5 with an associated spinal canal stenosis. The patient was treated with a spinal canal decompression and spondylodesis using the minimally invasive transforaminal lumbar interbody fusion (TLIF)1–3 technique. Pedicle screws were placed bilaterally pecutaneously under fluoroscopic guidance. A muscle-splitting tubular system was used on the left side for spinal canal decompression and transforaminal cage placement. There were no surgical complications. Preoperative MR imaging demonstrated a retropsoas course of the right iliac artery together with a very narrow anatomical relationship to the right L-4 nerve at its exit point from the intervertebral foramen that resulted in a limited nerve displacement (Fig. 1). In this setting the right iliac artery lies caudally and ventrally to the right L-4 transverse process (Fig. 2). This variation, although rare,4,5 can complicate this spondylodesis procedure because the search for the transverse process with the Yamshidi needle to achieve transpedicular insertion is blind and may result in an iliac artery laceration. The risk is accentuated in cases of right-sided sciatica that would necessitate an ipsilateral transmuscular tubular approach. Furthermore, the use of this minimally invasive approach for the treatment of a far-lateral disc herniation should be avoided. In conclusion, the retropsoas iliac artery is a very rare anatomical variation that can complicate lumbar spine surgery, and failure to identify it prior to a minimally invasive procedure may result in disastrous complications.

The authors report a very rare cause of low-back pain and sciatica in a patient with iliac vein thrombosis attributed to absence of the infrarenal segment of the inferior vena cava (IVC) with massively dilated venous collaterals draining via a paraspinal plexus into the azygous system. This 21-year-old man presented with acute low-back pain radiating to the left ventral thigh. The initial CT scan revealed an intraspinal lesion that mimicked lumbar disc herniation. Further clarification revealed an iliac vein thrombosis, which was triggered by the absence of the infrarenal segment of the IVC, a very rare vascular anomaly. Collateral venous return was developed and led to lumbar varicosities and epidural vein engorgements. Laboratory examinations revealed factor V mutation as a predisposing factor for thrombosis. The patient's symptoms were relieved with anticoagulation and antiinflammatory therapy. Absence of the infrarenal IVC associated with iliac vein thrombosis should be regarded as a very rare cause of radicular and low-back pain, and this condition can mimic the clinical and radiological signs of lumbar disc herniation. Sciatica might be the first clinical manifestation of this rare venous anomaly.

Background In the subgroup of bedridden hydrocephalic patients with ventriculo-peritoneal shunts and gravitational valves, we occasionally observed persisting hydrocephalic complaints even when mechanical or infection-related obstruction was excluded. Methods To investigate the cause of these hydrocephalic symptoms, in vitro and in vivo analyses were used to determine valve opening, intra-abdominal and hydrostatic pressure of an Aesculap-Miethke 10/40 cm H 2 O gravitational valve at different angles of upper body and head inclination. Findings Since hydrostatic pressure is lacking, the resulting intra-ventricular pressures are shown to peak up to 27 cm H 2 O in supine patients with head, but not upper body inclined. Conclusions We conclude that in the subgroup of bedridden patients with ventriculo-peritoneal shunts and gravitational valves, upright posture is a prerequisite for proper cerebrospinal fluid drainage.

Background Most adult patients with pyogenic lumbar or thoracic spondylodiscitis are treated with an external orthosis and antimicrobial therapy for several weeks to months. If surgical intervention is required, a combined anterior and posterior approach for debridement and fusion with autologous bone graft or titanium mesh cage is usually performed. Method We here report on our experience with the use of a minimally invasive percutaneous dorsal pedicle screw-rod spondylodesis in adult patients with pyogenic lumbar or thoracic spondylodiscitis. Findings Eight patients with lumbar, one with thoracolumbar and three with thoracic pyogenic spondylodiscitis with a mean back pain of 9/10 on the visual analog scale (VAS) and without corresponding neurological deficits were treated. Immediately after the operation, we calculated a significant reduction of the back pain on the VAS to 1.7, of leukocyte counts and C-reactive protein levels. After a mean of 61 days of continuous antimicrobial therapy during full mobilization, all patients were pain free, and leukocyte counts as well as C-reactive protein levels were normalized. Conclusions We conclude that minimally invasive percutaneous fixation is a feasible and effective technique to achieve immediate pain release, avoid long-term immobilization and overcome the disadvantages of a dorsoventral procedure. However, surgical complications and possible follow-up procedures supplement the patients' risks of adverse reactions of the disease.

OBJECT:Cerebellar hemorrhage is a life-threatening condition that requires immediate surgical intervention. Open craniectomy, hemorrhage evacuation and posterior fossa decompression is the treatment of choice. Patients with aspirin antithrombotic medication, however, face an increased risk of postoperative rebleeding, because it is impossible to normalize blood coagulation in time. To sufficiently treat these patients, we have developed a minimally-invasive, free-hand, bedside catheter evacuation technique.CLINICAL PRESENTATION:In a retrospective analysis, two patients with a mean age of 68 years and antithrombotic aspirin medication with cerebellar hemorrhage were treated. On admission, mean hemorrhage volume was 30.25 mL or 3.7x4.75x3.03 cm, mean GCS was 7.5, initial aspiration drained a mean 24 mL of blood. After a mean of 2.5 days of urokinase lysis, mean hemorrhage volume was 3.7 mL or 2.25x2.0x1.15 cm and mean EGOS on discharge was 4.5. After a mean follow-up of 408 days, the mean EGOS was 5.5, and both patients were alive.CONCLUSION:We conclude from these data that, in selected cases, bedside catheter placement and consequent urokinase lysis is a successful way to drain posterior fossa hemorrhage. However, experience in catheter positioning is crucial and the technique therefore should only be performed by experienced neurosurgeons.

BACKGROUND Predominantly isolated intracerebral hemorrhage (ICH) is a rare complication after traumatic brain injury that tends to occur in patients with coagulation disorders. METHODS We developed a minimally-invasive free-hand bedside catheter evacuation procedure using 3D-computerized tomography reconstruction imaging. Twelve patients were retrospectively analyzed. RESULTS Average duration of the procedure was approximately 15 minutes. After catheter placement, urokinase-lysis ensured successful hemorrhage evacuation. Mean Glasgow coma scale at admission was 10 and mean hemorrhage diameter was 6.3 x 3.9 x 4.2 cm, or 55 mL. Mean hemorrhage reduction was 37 mL or 66% in a mean of 4 days. No catheter-related complications were observed. The 30-day and 6-month mortality rates were 16%. Mean extended Glasgow outcome scale at discharge was 4. After a mean of approximately 19 months, nine patients had a favorable, two an unfavorable outcome. One was lost to follow-up. CONCLUSIONS In comparison with previously published results, free-hand bedside catheter evacuation is a quick and easy-to-apply technique to evacuate predominantly isolated traumatic supratentorial hemorrhage that can be performed in any intensive care unit.

OBJECTIVE:In bacterial shunt infection, CNS inflammation is a frequently observed complication that may cause vascular complications including vasospasms. Here, we describe the first patient with shunt infection-induced cerebral vasospasms.METHODS:A 35 year old woman with a ventriculoperitoneal shunt that was implanted years before developed facial nerve palsy and somnolence one week before admission to the hospital.RESULTS:After admission, the shunt was removed, and an external ventricular drainage was inserted. Microbiological analyses revealed coagulase-negative Staphylococcus on abdominal and cranial catheters. Follow-up NMR showed infarctions. Transcranial doppler sonography and cerebral arteriography revealed severe generalized cerebral vasospasms. Inspite of triple-H therapy and intraarterial spasmolysis, bilateral anterior and media artery infarction evolved. The patient was dismissed in a vegetative state.CONCLUSIONS:This case shows that severe cerebral vasospasms are a serious complication in patients with bacterial shunt infection that should be considered in patients, that don't improve following adequate antibiotic treatment.

✓The often extended and elongated configuration of a diffuse subdural hematoma of the spine makes it impossible to completely evacuate with common neurosurgical approaches. The authors describe the complete evacuation of a diffuse subdural hematoma of the entire spine due to trauma in a patient who suffered myelopathy and paraplegia in succession, by using transient subdural catheter lysis. After the patient underwent a partial hemilaminectomy at T7–8 and L2–3 using a lateral transmuscular approach, a 15 cm-long intraventricular catheter was inserted at each hemilaminectomy site and connected to an external ventricular drainage system in a procedure lasting 1 hour. Subsequently, 5000 IU of urokinase was applied four times daily for 30 minutes each time over the next 5 days. Two months later, the patient presented with spastic paraparesis Manual Muscle Test Grade 4/5. Magnetic resonance (MR) imaging revealed no catheter-related complications. The authors conclude from this case that transient catheter lysis may be an effective and gentle method to treat diffuse and elongated subdural hematomas of the spine due to trauma. A larger series needs to be analyzed, however, to address the indications and limitations of the technique compared with conventional open surgery. Such evaluation should include serial MR imaging and electrophysiological examination.

The association of electrocardiographic (ECG) abnormalities and intracerebral, particularly aneurysmal subarachnoid haemorrhage (SAH) is a well-known phenomenon. ECG alterations are observed in 50-100% of patients during the acute stage of SAH. Frequently, these effects are clinically not important. Some SAH patients, however, have structural cardiac damage with elevation of creatine kinase myocardial isoenzyme (CK-MB) and concomitant myocardial pathology. Accordingly, echocardiography has revealed abnormalities of left ventricular function in SAH patients.

In patients with traumatic brain injury (TBI), hypoperfusion contributes to ongoing and expanding areas of neuronal damage long after the initial trauma has ceased. In order to evaluate whether the antiangiogenic protein endostatin may play a role in this process, we analyzed its spatial distribution in brains of 18 patients with TBI. We observed an increase of endostatin/collagen XVIII(+) macrophages/microglial cells but not astrocytes up to day 14 and a consequent decrease to day 16 post-TBI. In addition, paracellular endostatin/collagen XVIII deposits were detected. In vitro experiments revealed that microglial endostatin release is induced predominantly by hypoxia and, to a lesser extent, by reactive oxygen intermediates. Common NO synthase inhibitor pharmacotherapy with aminoguanidine and L-NAME completely abolished endostatin release from microglial cells, raising hopes of altering endostatin release in vivo.

Objective: After the implementation of the G-DRG system in Germany, doubts arose whether and how interdisciplinary pain therapy centers should be restructured to remain profitable and maintain medical excellence for patients with a long ordeal of malaise. Methods: To reveal structural deficits, we performed a detailed economic analysis of all patients treated at an interdisciplinary pain therapy center of a German University hospital in 2004. Results: 3672 patients were treated: 2163 outpatients, 753 at the daycare clinic, 619 as consults and 132 inpatients. The costs for personnel were (sic) 736645.-, consumables (sic) 105 061.-. and infrastructure (sic) 277762.-. We calculated fixed costs of (sic) 236.-, and consurnables of (sic) 24.- per patient. The costs for surgery were (sic) 1595.-, and for a neuroradiological examination (sic) 245.- per patient. Overall treatment costs were (sic) 319.- per patient. We calculated an overall loss of (sic) 476 752.- or (sic) 109.19 per patient. Outpatients caused a total loss of 6 456 665.83 or (sic) 211.- per patient, consults a total loss of (sic) 161 683.16 or (sic) 261.20 per patient, daycare patients a slight profit of (sic) 30 370.- or E 40.- per patient and inpatients a total profit of (sic) 111 225.- or (sic) 135.- per day. Conclusion: Managerial optimization can yield considerable cost reductions in the G-DRG coding system, without any change in treatment strategies, selection of profitable patients or dismissal of personnel. Inversely, additional personnel are needed to accomplish the implementation process. Board certification was unveiled to constitute the key structural implementation that ensures the economic survival of the department and continuing medical excellence for the patients.

In patients with intracerebal hemorrhage, cardiac dysfunction is a common phenomenon. Tako-tsubo cardiomyopathy is characterized by complete reversibility and therefore may constitute an entity with a favorable outcome. In this case report the authors describe a previously healthy 23-year-old man with no history of cardiac disease who suffered a severe fourth ventricular hemorrhage due to an angioma of the vermis cerebelli. After emergency surgery, progressive tachycardia, fibrillation, and electromechanical decoupling developed in the patient. An echocardiogram revealed left ventricular apical akinesia and basal hyperkinesis characteristic of tako-tsubo cardiomyopathy. One week after admission, cardiac function was normal. Tako-tsubo cardiomyopathy differs from common cardiac dysfunction in its reversible nature. This characteristic must be taken into consideration when treating patients with intracerebral hemorrhage to avoid misclassification of the disease.

OBJECTIVES:We report on a patient with the combination of a peridural and a perimedullary spinal fistula, which manifested consecutively. The clinical course and diagnostic steps reveal important observations helpful in the management of this pathology. CASE PRESENTATION:A 61-year-old male patient presented with a six-month history of progressive weakness of the lower limbs. Magnetic resonance imaging revealed edema and dilated spinal veins of the lower thoracic spinal cord. Spinal angiography confirmed the diagnosis of spinal dural fistula at level T9 on the left. The patient underwent surgery and the fistula was surgically excised. Two months after initial improvement, the clinical symptoms of lower limb weakness recurred. On re-angiography a spinal perimedullary fistula was found at level T7 that was not apparent on the previous angiogram and on the postoperative control angiogram. The patient underwent surgery again, and the second fistula was also excised. The clinical symptoms subsequently improved. CONCLUSION:The interesting point in this case was the rare combination of a peridural and a perimedullary spinal fistula. They presented consecutively and could not be identified simultaneously on the first angiogram. Only after closure of the first fistula did the second become apparent. We believe that this may be a result of a postoperative pressure change in the venous system of the cord. After closure of the first fistula, the arterio-venous (AV) shunt of the second fistula developed gradually. The possibility of a second fistula should be considered in the presence of persistent edema of the cord on magnetic resonance imaging (MRI) and subsequent clinical deterioration.

Endostatin is a 20 kDa carboxyl-terminal fragment of collagen XVIII that, when added exogenously, inhibits endothelial proliferation and migration in vitro and angiogenesis and tumor growth in vivo. Previous results showed endostatin/collagen XVIII labeling in few endothelial cells in human glioblastoma multiforme. We have now observed constitutive release of endostatin from one of four endothelial cell lines. Induction of endostatin release was observed after H2O2, an in vitro model of cell stress, CoCl2, a model of hypoxia, and by IFN-gamma challenge. Endostatin expression and release was reduced by the nitric oxide synthase inhibitors aminoguanidine and L-NAME and induced by the NO synthase-independent NO donors sodium nitroprusside (SNP) and spermine-NONO-ate. SNP-mediated endostatin induction was abrogated by the soluble guanylate cyclase inhibitor 1H-(1.2.4) oxadiazolo (4,3-A) quinoxalin-1-one. Adenoviral endostatin transduction resulted in the release of endostatin from endothelial cells and in down-regulation of iNOS (NOS2) and eNOS (NOS3), and surprisingly in a 10% induction of PCNA. These results describe the modulation of endostatin release by the NO signaling cascade and provide important new pharmacological information for the systemic induction of endogenous endostatin release by common NO donor pharmacotherapy.

In cerebral malaria (CM), microvascular activation accompanies blood-brain barrier dysfunction which in turn represents the pathophysiological basis of neurological impairments in affected patients. To dissect the molecular basis of this process, we analyzed localization of proangiogenic vascular endothelial growth factor (VEGF), its receptor vascular endothelial growth factor receptor-1 (VEGFR-1, Flt-1), of downstream VEGF effectors matrix-metalloproteinase-1 (MMP-1) and connective tissue growth factor (CTGF), and of VEGF-interacting antiangiogenic thrombospondin-1 and -independent angiostatin in brains of patients who died with CM and controls by immunohistochemistry and Western blotting experiments. Most prominently, we detected more VEGF(+) astrocytes in CM patients and deposition of Flt-1 in Dürck's granulomas. MMP-1 and thrombospondin-1 accumulated in macrophages/microglial cells in Dürck's granulomas. In one CM patient, massive amounts of CTGF were detected as perivascular paracellular deposits. Angiostatin was observed in the serum of 2/7 control but in no CM patients. These data demonstrate the activation of the proangiogenic VEGF signaling cascade in patients with CM, probably reflecting compensatory mechanisms of general and focal brain hypoxia observed in these patients.

CD14 is a membrane-bound lipopolysaccharide receptor or, lacking the glycosylphosphatidylinositol anchor, is secreted to modulate cellular and humoral immune response by interacting directly with T and B cells. Because immunodepletion is thought to contribute to the grim prognosis of glioblastoma patients, we analyzed expression and release of CD14 in rat and human astrocytomas and glioma cell lines. Immunohistochemistry of 50 glioma biopsy specimens from low-grade diffuse astrocytoma (WHO grade II), anaplastic astrocytoma (WHO grade III) and glioblastoma (WHO grade IV), and of the C6 rat glioma model demonstrated significantly more CD14-immunoreactive macrophages/microglial cells in glioblastomas than in less malignant gliomas. In WHO grade II and III astrocytomas, only perivascular cells showed immunoreactivity with CD14. In glioblastomas, CD14-immunoreactive cells were mainly found scattered throughout the entire tumor parenchyma. Double labeling experiments demonstrated CD14 immunoreactivity predominantly in CD68-expressing macrophages/microglial cells and some glioma cells. Western blotting, reverse transcription-PCR and consecutive sequencing confirmed expression and release of CD14 by four of six analyzed glioma cell lines. These results demonstrate that CD14 is expressed, and more importantly released, from a subset of human glioma cells and infiltrating macrophages/microglial cells that may contribute to immunodepletion observed in these patients.

Cyclooxygenases (COXs) mediate inflammation, immunomodulation, blood flow, apoptosis, and fever in various diseases of the brain. Whereas COX-2 is cytokine inducible, COX-1 is expressed by macrophages/microglial cells that accumulate in pathological foci. We analyzed the localization of COX-1 and COX-2 in postmortem cortex slices of eight patients who died with sporadic Creutzfeldt-Jakob disease (CJD) and four neuropathologically unaltered controls by immunohistochemical double-labeling, reverse transcriptase polymerase chain reaction (RT-PCR), and Western blotting experiments. In healthy brains, COX-1 was expressed by single macrophages/microglial cells and COX-2 by disseminated neurons. In patients with CJD, significantly (p = 0.0195) more COX-1-expressing macrophages/microglial cells were detected adjacent to neurons. COX-2 expression was predominantly observed in neurons, and their number was significantly higher (p < 0.0001) compared to controls. RT-PCR and Western blotting revealed more COX-1 and COX-2 mRNA and protein in one CJD patient than in one control patient. These data show that accumulation of COX-1-expressing macrophages/microglial cells and COX-2-expressing neurons might represent important regulatory mechanisms in the complex process of neuronal degeneration in CJD patients.