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Prognosticating the clinical outcome of neurological diseases is essential to guide treatment and facilitate decision-making. It usually depends on clinical and radiological findings. Biomarkers have been suggested to support this process, as they are deemed objective measures and can express the extent of tissue damage or reflect the degree of inflammation. Some of them are specific, and some are not. Few of them, however, reached the stage of daily application in clinical practice. This mini review covers available applications of the S100B protein in prognosticating clinical outcome in patients with various neurological disorders, particularly in those with traumatic brain injury, spontaneous subarachnoid hemorrhage and ischemic stroke. The aim is to provide an understandable picture of the clinical use of the S100B protein and give a brief overview of the current limitations that require future solutions.

Background Retroperitoneal and pelvic schwannomas and neurofibromas account about 10% of all retroperitoneal tumors. These tumors are almost invariably benign and slow growing. They are either asymptomatic or cause radicular or abdominal pain. The radiologic findings cannot distinguish schwannomas from other retroperitoneal neoplasms. To our knowledge, this study is the first neurosurgical series of this size to employ intraoperative electrophysiological monitoring during resection of schwannomas and neurofibromas arising in the retroperitoneal and pelvic regions. Methods A retrospective study conducted at the University Hospital Göttingen from 2015 to 2024 included 13 patients who underwent surgical treatment for schwannomas and neurofibromas arising in the retroperitoneal and pelvic regions. The study incorporated detailed surgical descriptions of the resection techniques and the approaches used for these tumors. Results The mean age was 51 ± 12 years. Symptomatic presentations included abdominal discomfort in 6 patients (46%), unilateral radicular pain in 5 patients (38%), and 4 patients (31%) were asymptomatic. Tumors exhibited a mean diameter of 6.2 ± 2.9 cm (range: 3.3–14 cm). Anatomic distribution included 7 cases (54%) in the presacral region, 5 cases (38%) in the lesser pelvis, and 4 cases (31%) involving the L5 or S1 neuroforamen with extension into the ventral prevertebral space. Transretroperitoneal approaches were utilized in 8 cases (62%), while 5 (38%) underwent transperitoneal resection. Gross total resection was achieved in 10 patients (77%). In one patient, a transient intraoperative decline in sphincter MEPs was observed, with a 48% drop in amplitude, followed by full postoperative recovery. Direct electrical stimulation of the tumor capsule elicited active motor responses in 5 patients (38%). In 3 of these cases, complete resection was not feasible due to intraoperative changes in MEPs signals. The mean operative duration was 271.8 ± 64.5 min (range: 180–400 min), with a mean blood loss of 700 ± 400 mL. Postoperatively, no motor or sensory deficits occurred, and symptoms resolved within one week. The mean hospital stay was 9.2 ± 3.5 days (range: 5–15 days). Histopathology confirmed benign tumors in all cases: 8 schwannomas (62%), 3 neurofibromas (23%), and 1 ganglioneuroma (8%). No recurrences were observed during a mean follow-up period of 24 ± 6 months. Conclusion Surgical resection of retroperitoneal and pelvic schwannomas and neurofibromas, while technically challenging, is safe and effective when performed by experienced surgeons and multidisciplinary preoperative planning. None of our patients experienced postoperative complications, which may, in part, be attributable to the use of intraoperative neuromonitoring. However, comparative and prospective studies are recommended to further validate these findings.

Robotic-guided and percutaneous pedicle screw placement are emerging technologies. We here report a retrospective cohort analysis comparing conventional open to open robotic-guided and percutaneous robotic-guided pedicle screw placement. 112 patient records and CT scans were analyzed concerning the intraoperative and perioperative course. 35 patients underwent percutaneous, 20 open robotic-guided and 57 open conventional pedicle screw placement. 94.5% of robot-assisted and 91.4% of conventionally placed screws were found to be accurate. Percutaneous robotic and open robotic-guided subgroups did not differ obviously. Average X-ray exposure per screw was 34 s in robotic-guided compared to 77 s in conventional cases. Subgroup analysis indicates that percutaneously operated patients required less opioids, had a shorter hospitalization and lower rate of adverse events in the perioperative period. The use of robotic guidance significantly increased accuracy of screw positioning while reducing the X-ray exposure. Patients seem to have a better perioperative course following percutaneous procedures.

Fibrinolytic therapy with tissue plasminogen activator (rtPA) is considered a promising treatment option for intracerebral hemorrhage (ICH), but a large randomized controlled study (i.e., MISTIE III) failed to show a benefit for the long-term outcome. This study investigated whether the rapidity of hematoma volume reduction influences outcome of ICH-patients undergoing fibrinolytic therapy. Patients with supratentorial ICH with or without a secondary extension to the ventricular system receiving fibrinolytic therapy from 2010 to 2020 were retrospectively analyzed. Patients with primarily intraventricular hemorrhage were excluded. A catheter was placed into the hematoma via burr hole and by means of neuronavigation. After confirming a correct catheter position rtPA was injected through the catheter with subsequent passive drainage of the hematoma. Hematoma volume was measured initially and 24/48/72 hours after treatment and the relative volume reduction was calculated. The functional outcome at discharge was assessed using the modified Rankin scale (mRS) regarding a mRS of 4 or lower as favorable outcome. A total of 280 patients with mean age of 69.6 years and mean hematoma volume of 55.6 ml were analyzed. The odds of reaching favorable outcome were four-fold higher in patients with a volume reduction of more than 50% after 24 h (OR 4.23, 95%CI 3.05 to 5.66, p  = 0.007). Patients with a residual volume of less than 30 ml after 24 h had a two-fold higher chance of having favorable outcome (OR 2.9, 95%CI 1.78 to 4.63, p  < 0.0001). A fast volume reduction of at least 50% within 24 h resulted into a favorable outcome in ICH-patients undergoing fibrinolytic therapy. Not just the amount but also the rapidity of hematoma volume reduction seems to be an important factor for a good clinical result after fibrinolytic therapy.

Aneurysmal subarachnoid hemorrhage (aSAH) not only causes neurological deficits but also influences extracerebral organ functions. The Logistic Organ Dysfunction System (LODS) reliably captures organ dysfunctions and predicts mortality of critically ill patients. This study investigated LODS in the setting of aSAH as a surrogate marker for early brain injury (EBI). Patients with aSAH treated between 2012 and 2020 were retrospectively analyzed. LODS was calculated within 24 h upon admission applying functional parameters for each organ system. The EBI was evaluated based on 1-persistent loss of consciousness, 2-global cerebral edema, and 3-intracranial blood burden. The outcome was assessed with the modified Rankin scale (mRS) at 3-months after ictus (mRS > 2 = unfavorable outcome). A total of 324 patients with a mean age of 55.9 years were included. Severe EBI (EBI grade ≥ 3) was found in 38% (124/324) of patients. Higher LODS score correlated with severe EBI ( p  < 0.0001) and poor outcome ( p  < 0.0001). LODS with a cutoff of 7 allowed a reliable discrimination (AUC 78%, p  < 0.0001) of patients with severe from those with mild EBI. The LODS-calculation as an early risk stratification and prognostic tool reliably reflected the severity of EBI after aSAH and correlated with outcome.

Disturbed cerebral autoregulation (CA) increases the dependency of cerebral blood flow (CBF) on cerebral perfusion pressure (CPP). Thus, induced hypertension (IHT) is used to prevent secondary ischemic events. The pressure reactivity index (PRx) assesses CA and can determine the optimal CPP (CPPopt). This study investigates CPPopt in patients with subarachnoid hemorrhage (SAH) treated with IHT and its impact on delayed cerebral infarction and functional outcome. This is a retrospective observational study including SAH patients treated between 2012 and 2020. PRx defines the correlation coefficient of intracranial pressure (ICP) and the mean arterial pressure (MAP). The CPP corresponding to the lowest PRx-value describes CPPopt. Primary outcome parameters were deleayed cerebral infarction and functional outcome. In patients without IHT, higher deviations of measured CPP from CPPopt were associated with delayed cerebral infarction ( p  = 0.001). Longer time spent with a CPP below the calculated CPPopt during IHT led to an increased risk of developing delayed cerebral infarction ( r  = 0.39, p  = 0.002). A larger deviation of measured CPP from CPPopt correlated with an unfavorable outcome in patients treated with IHT ( p  = 0.04) and without IHT ( p  = 0.0007). Patients with severe aneurysmal SAH may benefit from an individualized CPP management and the calculation of CPPopt may help to guide IHT.

The coronavirus disease 2019 (COVID-19) pandemic poses an unprecedented challenge to health-care systems around the world. As approximately one-third of the world´s population is living under \"lockdown\" conditions, medical resources are being reallocated and hospital admissions are limited to emergencies. We examined the decision-making impact of these actions and their effects on access to hospital treatment in patients with neurosurgical conditions. This retrospective cohort study analyzes hospital admissions of two major neurosurgical services in Germany during the nationwide lockdown period (March 16th to April 16th, 2020). Spinal or cranial conditions requiring immediate hospital admission and treatment constituted emergencies. A total of 243 in-patients were treated between March 16th and April 16th 2020 (122 patients at the University Medical Center Mainz, 121 patients at the University Medical Center Göttingen). Of these, 38.0±16% qualified as emergency admission. Another 1,688 admissions were reviewed during the same periods in 2018 and 2019, providing a frame of reference. Overall, emergency admissions declined by 44.7±0.7% during lockdown. Admissions for cranial emergencies fell by 48.1±4.44%, spinal emergencies by 30.9±14.6%. Above findings indicate that in addition to postponing elective procedures, emergency admissions were dramatically curtailed during the COVID-19 lockdown. As this surely is unexpected and unintended, reasons are undoubtedly complex. As consequences in morbidity and mortality are still unpredictable, efforts should be made to accommodate all patients in need of hospital access going forward.

The amount of extravasated blood is an established surrogate marker for subarachnoid hemorrhage (SAH) severity, which varies in different experimental SAH (eSAH) models. A comprehensive eSAH grading system would allow a more reliable correlation of outcome parameters with SAH severity. The aim of this study was to define a severity score for eSAH related to the Fisher-Score in humans. SAH was induced in 135 male rats using the modified double hemorrhage model. A sham group included 8 rats, in which saline solution instead of blood was injected. Histological analysis with HE(hematoxylin-eosin)-staining for the visualization of blood was performed in all rats on day 5. The amount and distribution of blood within the subarachnoid space and ventricles (IVH) was analyzed. The mortality rate was 49.6% (71/143). In all except five SAH rats, blood was visible within the subarachnoid space. As expected, no blood was detected in the sham group. The following eSAH severity score was established (ESAS-score): grade I: no SAH visible; grade II: local or diffuse thin SAH, no IVH; grade III: diffuse / thick layers of blood, no IVH; grade IV: additional IVH. Grade I was seen in five rats (7.9%), grade II in 28.6% (18/63), grade III in 41.3% (26/63) and grade IV in 22.2% (14/63) of the rats with eSAH. The double hemorrhage model allows the induction of a high grade SAH in more than 60% of the rats, making it suitable for the evaluation of outcome parameters in severe SAH.

Decompressive craniectomy (DHC) can prevent mortality in patients with malignant ischemic stroke. However, no clear criteria have been established to early identify patients, who will develop malignant stroke requiring DHC. In this retrospective observational study, a large patient cohort with ischemic stroke treated between 2010 and 2021, was analyzed. Clinical and radiological parameters were analyzed. Univariate and multivariate regression analyses were performed to identify the parameters to be included in the score. A cohort of 534 patients was included. A malignant stroke indicator (MSI) score was created including age < 70 years with 7 points, midline shift with up to 6 points, unsuccessful recanalization (TICI < 2b) with 6 points, basal cistern effacement with 4 points, and CBV ASPECTS < 6 with 3 points assigned. A MSI score with a cutoff value of 9 showed a high discrimination power concerning the need for DHC (AUC 0.90, p  < 0.0001). Patients with MSI-score ≥ 9 had a 22-fold higher probability of needing DHC (odds ratio 22.90, p  < 0.0001). The MSI score is a promising tool to predict the need for DHC in patients at risk for developing a malignant stroke and needs to be validated in external cohorts.

PurposeUnilateral hemilaminectomy with bilateral decompression (BDZ) was proposed as an alternative decompressive procedure in cervical spondylotic myelopathy (CSM). Despite promising clinical results, the destabilizing effect is yet unknown. We therefore performed a biomechanical study to investigate whether lateral mass screw fixation should follow BDZ.MethodsSix human C2–C7 cervical specimens were tested under various conditions: native, unilateral hemilaminectomy with bilateral decompression without/with fixation (BDZ/BDF), unilateral hemilaminectomy with bilateral decompression and unilateral foraminotomy without/with fixation (UFZ/UFF), unilateral hemilaminectomy with bilateral decompression and bilateral foraminotomy without/with fixation (BFZ/BFF), and laminectomy without/with fixation (LAZ/LAF). Instrumention was applied from C3–C6. For each condition, the three-dimensional kinematics of the cervical specimen were measured in three main loading directions with an ultrasonic motion analysis system. ANOVA was used to determine differences between the specific segment conditions to assess the parameter’s range of motion (ROM) and neutral zone (NZ).ResultsFor flexion–extension, lateral bending and axial rotation, ROM of BDZ, UFZ, BFZ and LAZ remained at the level of the native condition (p > 0.74), whereas fixation reduced ROM significantly (p < 0.01). Between BDF, UFF, BFF and LAF, no significant differences in reduction in ROM were seen (p > 0.49). Results for NZ were equivalent to ROM in flexion–extension and lateral bending. For axial rotation, NZ remained almost constant on the native level for all tested conditions.ConclusionBilateral decompression via a hemilaminectomy, even if combined with foraminotomy, could be a less invasive treatment option for multilevel CSM in patients with lordotic cervical alignment and absence of segmental instability.