http://repub.eur.nl/res/aut/30427/ List of Publications en http://repub.eur.nl/static-eur/img/logo.png http://repub.eur.nl http://repub.eur.nl/res/pub/39473/ 2013-03-19T00:00:00Z No class I evidence exists about the optimal treatment of chronic subdural hematoma (CSDH). The aim of this study was to evaluate current practice of CSDH patients with different neurological grades, and probable ambivalence towards various treatment paradigms, especially primary treatment with high-dose corticosteroids, among vascular neurologists and neurosurgeons. A questionnaire survey containing 4 questions, 1 consisting of cases, was sent to every vascular neurologist (n = 83) and neurosurgical centre (n = 15) in the Netherlands. The various treatment options were related to the treating physician, geographical distribution, both in general and for individual case. Sixty-two percent of surveys were returned. The proportion of patients primarily treated with corticosteroids was 17. 5 % in 2009 and 20. 5 % in 2010. Surgery by either burr holes or craniotomy was favoured by 61. 1 % as primary treatment, and conservative treatment with corticosteroids by 22. 4 %. Case studies revealed that surgery was preferred in case of severe neurological symptoms, whereas wait-and-see policy was preferred in case of mild symptoms without midline shift, of which 28 % would administer corticosteroids. Variety in answers was obtained in less pronounced cases. In the Netherlands, neurologists and neurosurgeons appear to favour surgery in CSDH patients as primary treatment, especially in severe cases. An ambivalent approach towards treatment protocols was shown, especially in patients with mild symptoms, regardless of hematoma size. A regimen of high-dose corticosteroids only, is preferred by about a quarter and predominantly in milder cases, and might depend on geographical distribution. These results suggest the need for a well-designed randomized trial. http://repub.eur.nl/res/pub/27510/ 2010-11-01T00:00:00Z Background: Previously, we reported on our single centre results regarding the diagnostic yield of stereotactic needle biopsies of brain lesions. The yield then (1996-2006) was 89.4%. In the present study, we review and evaluate our experience with intraoperative frozen-section histopathologic diagnosis on-demand in order to improve the diagnostic yield. Methods: One hundred sixty-four consecutive frameless biopsy procedures in 160 patients (group 1, 2006-2010) were compared with the historic control group (group 2, n∈=∈164 frameless biopsy procedures). Diagnostic yield, as well as demographics, morbidity and mortality, was compared. Statistical analysis was performed by Student's t, Mann-Whitney U, Chi-square test and backward logistic regression when appropriate. Results: Demographics were comparable. In group 1, a non-diagnostic tissue specimen was obtained in 1.8%, compared to 11.0% in group 2 (p∈=∈0.001). Also, both the operating time and the number of biopsies needed were decreased significantly. Procedure-related mortality decreased from 3.7% to 0.6% (p∈=∈0.121). Multivariate analysis only proved operating time (odds ratio (OR), 1.012; 95% confidence interval (CI), 1.000-1.025; p∈=∈0.043), a right-sided lesion (OR, 3.183; 95% CI, 1.217-8.322; p∈=∈0.018) and on-demand intraoperative histology (OR, 0.175; 95% CI, 0.050-0.618; p∈=∈0.007) important factors predicting non-diagnostic biopsies. Conclusions: The importance of a reliable pathological diagnosis as obtained by biopsy must not be underestimated. We believe that when performing stereotactic biopsy for intracranial lesions, next to minimising morbidity, one should strive for as high a positive yield as possible. In the present single centre retrospective series, we have shown that using a standardised procedure and careful on-demand intraoperative frozen-section analysis can improve the diagnostic yield of stereotactic brain biopsy procedures as compared to a historical series. http://repub.eur.nl/res/pub/28184/ 2010-10-01T00:00:00Z Purpose of review: Antiepileptic agents are widely used in the perioperative course of neurosurgical patients - for prophylactic and therapeutic reasons. However, the evidence supporting their use is extremely small and adverse events are common. This review highlights the current controversies. Recent findings: Prophylactic use of antiepileptic agents is unfavorable for patients with subarachnoid hemorrhage. In patients with brain tumors, prophylactic use is not recommended. If the drugs are used nevertheless, stopping after the first postoperative week must be strongly recommended. After traumatic brain injury, early prophylactic use might prevent late post-traumatic seizures. The new antiepileptic drug levetiracetam seems to have a better safety profile, which makes it more suitable for prophylactic use. However, in all groups, evidence concerning the choice of drugs and duration of prophylaxis is lacking. Current research is focusing on prevention of epileptogenesis. Therapeutic use of antiepileptic drugs is supported by evidence. These drugs should be continued perioperatively. However, they might induce severe adverse events during adjuvant treatments like radiotherapy or chemotherapy in patients with brain tumors. Summary: Despite lacking evidence, prophylactic antiepileptic drug use is common in the perioperative course of neurosurgical patients. More research is needed to deal better with epileptogenesis and to define the right drug for the right patient at the right time. http://repub.eur.nl/res/pub/27748/ 2010-05-01T00:00:00Z http://repub.eur.nl/res/pub/24305/ 2009-11-01T00:00:00Z Objective and importance: We present a very unusual case in which a proximal posterior inferior cerebellar artery (PICA) aneurysm was located extracranially. We reviewed the PICA origin anatomy and pathology of aneurysms at this site. Clinical presentation: A Caucasian woman, 52 years of age, presented with a lesion at the craniocervical junction. She complained only of headache off and on without other symptoms. Her physical examination was unremarkable. A CT angiography clearly visualized an approximately 9-mm wide aneurysm of the right PICA which lay intradurally in the spinal canal at the C1-level. Surgery was planned. However, six weeks after her initial referral and just before her surgical date, the patient suffered a subarachnoid haemorrhage. Physical examination at that time showed a lethargic but conscious patient, with slight disorientation (Glasgow Coma Score 14; Hunt and Hess grade III). Intervention: The aneurysm was successfully treated by microneurosurgical techniques via a suboccipital craniotomy with laminectomy of C1as well. Temporary clipping of the PICA was feasible and the aneurysm could be dissected and clipped appropriately. Conclusion: The present report underscores the anatomical variants of the PICA. Although uncommon, PICA aneurysms do occur and caretakers should be aware of this when treating patients with clinical signs or CT evidence of subarachnoid haemorrhage. Even extracranial PICA aneurysms can be encountered, either through a caudal loop or an early extracranial lateral medullary segment. We stress the use of four vessel angiography or CT angiography with thin cuts to rule out such aneurysms. http://repub.eur.nl/res/pub/24965/ 2009-03-01T00:00:00Z OBJECTIVE: In menitigioma surgery, the completeness of resection is of great importance with regard to prognosis and recurrence. This is more difficult in meningiomas en plaque and cranial base meningiomas, which often involve the bone of the cranial base. We present a case in which radioguided resection of a meningioma using111indium-labeled somatostatin receptors enhanced the extent of the resection and describe how this could be of potential use in maximizing resection of meningiomas involving the cranial base region. METHODS: A 45-year-old woman presented with a history of headache and no neurological deficits. Magnetic resonance imaging of the brain revealed a large enhancing extra-axial mass involving the left sphenoid wing region, suggestive of a meningioma. A somatostatin analog scintigram using111In-labeled pentetreotide was obtained 24 hours preoperatively. This showed abnormal uptake in the left frontal region, consistent with a meningioma, because of the abundance and high affinity of somatostatin receptors in meningiomas. Intraoperatively, a radiation detection probe guided the resection until no gamma radiation could be discerned. RESULTS: A postoperative magnetic resonance imaging scan and scintigram showed complete resection of the meningioma. CONCLUSION: Radioguided surgery of meningiomas by labeling them with111In is an innovative and feasible approach to help guide and maximize meningioma resection, especially those involving the cranial base region. This technique should be used further and studied to achieve better resection of meningiomas in general and of those involving the cranial base in particular. http://repub.eur.nl/res/pub/28905/ 2008-01-01T00:00:00Z Background. Frameless stereotaxy or neuronavigation has evolved into a feasible technology to acquire intracaranial biopsies with good accuracy and little mortality. However, few studies have evaluated the diagnostic yield, morbidity, and mortality of this technique as compared to the established standard of frame-based stereotactic brain biopsy. We report our experience of a large number of procedures performed with one or other technique. Patients and methods. We retrospectively assessed 465 consecutive biopsies done over a ten-year time span; Data from 391 biopsies (227 frame-based and 164 frameless) were available for analysis. Patient demographics, peri-operative characteristics, and histological diagnosis were reviewed and then information was analysed to identify factors associated with the biopsy not yielding a diagnosis and of it being followed by death. Results. On average, nine tissue samples were taken with either stereotaxy technique. Overall, the biopsy led to a diagnosis on 89.4% of occasions. No differences were found between the two biopsy procedures. In a multiple regression analysis, it was found that left-sided lesions were less likely to result in a non-diagnostic tissue sample (p = 0.023), and cerebellar lesions showed a high risk of negative histology (p = 0.006). Postoperative complications were seen after 12.1% of biopsies, including 15 symptomatic haemorrhages (3.8%). There was not a difference between the rates of complication after either a frame-based or a frameless biopsy. Overall, peri-operative complications (p = 0.030) and deep-seated lesions (p = 0.060) increased the risk of biopsy-related death. Symptomatic haemorrhages resulting in death (1.5% of all biopsies) were more frequently seen after biopsy of a fronto-temporally located lesion (p = 0.007) and in patients with a histologically confirmed lymphoma (p = 0.039). Conclusions. The diagnostic yield, complication rates, and biopsy-related mortality did not differ between a frameless biopsy technique and the established frame-based technique. The site of the lesion and the occurrence of a peri-operative complication were associated with the likelihood of failure to achieve a diagnosis and with death after biopsy. We believe that using intraoperative frozen section or cytologic smear histology is essential during a stereotactic biopsy in order to increase the diagnostic yield and to limit the number of biopsy specimens that need to be taken. http://repub.eur.nl/res/pub/35435/ 2007-05-01T00:00:00Z http://repub.eur.nl/res/pub/36327/ 2007-02-01T00:00:00Z Computerized tomography (CT) scanning provides an objective assessment of the structural damage to the brain following traumatic brain injury (TBI). We aimed to describe and quantify the relationship between CT characteristics and 6-month outcome, assessed by the Glasgow Outcome Scale (COS). Individual patient data from the IMPACT database were available on CT classification (N = 5209), status of basal cisterns (N = 3861), shift (N = 4698), traumatic subarachnoid hemorrhage (tSAH) (N = 7407), and intracranial lesions (N = 7613). We used binary logistic and proportional odds regression for prognostic analyses. The CT classification was strongly related to outcome, with worst outcome for patients with diffuse injuries in CT class III (swelling; OR 2.50; CI 2.09-3.0) or CT class IV (shift; OR 3.03; CI 2.12-4.35). The prognosis in patients with mass lesions was better for patients with an epidural hematoma (OR 0.64; CI 0.56-0.72) and poorer for an acute subdural hematoma (OR 2.14; CI 1.87-2.45). Partial obliteration of the basal cisterns (OR 2.45; CI 1.88-3.20), tSAH (OR 2.64; CI 2.42-2.89), or midline shift (1-5 mm-OR 1.36; CI 1.09-1.68); >5 mm-OR 2.20; CI 1.64-2.96) were strongly related to poorer outcome. Discrepancies were found between the scoring of basal cisterns/shift and the CT classification, indicating observer variation. These were less marked in studies that had used a central review process. Multivariable analysis indicated that individual CT characteristics added substantially to the prognostic value of the CT classification alone. We conclude that both the CT classification and individual CT characteristics are important predictors of outcome in TBI. For clinical trials, a central review process is advocated to minimize observer variability in CT assessment.