Bypass – Surgery and Coil – Embolisation in the Treatment of Cerebral Giant Aneurysms

Summary  Objective. Operative clipping is the most effective method in the treatment of cerebral giant aneurysms. But about 50% of all giant aneurysms are treatable this way. We want to report about eight patients with giant cerebral aneurysms, which were in our opinion “unclippable” without causing ischaemia in depending brain areas.  Methods. We describe eight cases of giant aneurysms of the pericallosal artery (n=1), the middle cerebral artery (n=3), the basilar tip (n=3) and of the upper part of the basilar artery (n=1). One patient with an aneurysm of the pericallosal artery was treated with an extra-intracranial saphenous vein bypass saphenous bypass, in three cases of middle cerebral artery aneurysms an extra-intracranial bypass was also done combined with a resection of the aneurysm. The four patients suffering from an aneurysm of the basilar artery got an extra intracranial bypass too followed by an occlusion of the aneurysm with GD-Coils.  Results. There was no peri-operative mortality and no severe peri- or postoperative complication. The neurological symptoms of all patients were unchanged after the operation. An angiographic controll showed a complete obliteration of the aneurysm and a free running bypass in all cases.  Conclusion. Bypass surgery and combined bypass surgery and coil embolisation are effective methods in the treatment of giant cerebral aneurysms, which can not be treated by clipping alone.     

Multi-Slice 3D-CTA – An Improvement Over Single Slice Helical CTA for Cerebral Aneurysms

Summary. Summary.   Background and Objective: The aim of this study was to demonstrate the utility of volume rendered multi-slice helical three-dimensional CT angiography in patients with cerebral aneurysm when compared with single slice CT angiography and formal digital subtraction angiography.   Methods: A prototype Toshiba Aquilon multi-slice CT scanner was employed with the following scan conditions: voltage 135 kV; current 300 mA; slice thickness 0.8 mm; scan speed 0.75 sec/cycle; couch speed 1 mm/sec; range 50 mm from foramen magnum; scan pitch 3; three dimensional images were reconstructed using multiple image projections and integral volume rendering algorithms on a Xlink/Xtension workstation. 80 cases of multi-slice CTA for cerebral aneurysm carried out at Fujita University from January 1999 to January 2001 were reviewed.   Results: The advantages of multi-slice imaging are illustrated with representative cases of cerebral aneurysm – good demonstration of three dimensional anatomy, appreciation of perforators down to 1 mm in size, delineation of the vessels around the aneurysm complex, relationship between the aneurysm and skull base, information on calcification, thrombus and blebs in the wall and eleven routine views for perusal.   Conclusion: Multi-slice CTA is a significant improvement over single slice CTA for cerebral aneurysms. It is our experience the superior and precise images produced by multi-slice technology displays anatomical information not readily available from standard DSA. Multislice 3D-CTA is relatively non-invasive and provides better and adequate detail for surgical planning. The basis of multi-slice CT angiography is described. Multi slice CTA is changing the way cerebral aneurysms are being managed nowadays. New advances in the technology of multi-slice CTA resulting in increased image resolution are outlined. Published online July 18, 2002     

Cerebral Aneurysms in the Perforating Artery Manifesting Intracerebral and Subarachnoid Haemorrhage – Report of two Cases

BACKGROUND: An arteriosclerotic aneurysm in the perforating artery has been focused on as a causative factor for hypertensive intracerebral haemorrhage. However, its pathogenesis remains unknown, and its existence is still a controversy. CASE DESCRIPTION: A 62-year-old female and a 70-year-old male with a history of hypertension suffered from intracerebral haemorrhage accompanied by subarachnoid haemorrhage. Cerebral angiograms demonstrated an aneurysm arising from the perforating artery at the central location of the haematoma in both cases. The aneurysms were confirmed as the cause of bleeding during microsurgery, and were resected. Histological examination of the surgical specimens revealed that the walls of the aneurysms lacked internal elastic lamina and consisted only of the adventitia. CONCLUSION: These findings demonstrate that the aneurysm in the perforating artery can be a causative factor for hypertensive intracerebral haemorrhage, and indicate that the loss of internal elastic lamina induced by hypertension may contribute to the formation of the aneurysm of the perforating artery.     

Keimzelltumoren – ein Update

Recently a rise in the incidence of testicular germ cell cancer (TGCC) has been repeatedly reported in Germany (18% during the period 2000–2006). Future investigations are needed to examine causes for this increase in TGCT. The mortality rates in the western and eastern parts of Germany converge, but there is still a significantly higher mortality rate in the eastern part. Again future investigations are needed to examine causes for this phenomenon. In cases of testicular microlithiasis, testicular biopsies should be considered if further factors representing testicular dysgenesis syndrome are present, such as infertility, atrophic testes, and undescended testes. One course of adjuvant BEP reduces the risk of relapse by approximately 90% and may be a new option as the initial treatment for all CS1 NSGCT. Patients obtaining a CR (<1 cm) after first-line chemotherapy can be safely observed without PC-RPLND. Relapses are rare and potentially curable with further treatment.     

Wilms-Tumor – Update 2007

Due to the close interdisciplinary work of surgeons, radiologists and oncologists, the prognosis for Wilms' tumor (the most common renal tumor in childhood) has been dramatically improved over the last few decades. The treatment of such tumors is currently carried out worldwide by two study groups, in North America the National Wilms' Tumor Study (NWTS) and in Europe the Society of Paediatric Oncology (SIOP). Here we present an overview of the current treatment results and discuss future diagnostic and therapeutic strategies.     

Urinzytologie – Update 2013

Urine cytology is an important element of the diagnosis and follow-up of urothelial carcinomas and is recommended in most relevant guidelines. Urine-based marker systems are advocated as an adjunct to or a replacement of urine cytology. Urine cytology also has its place in the diagnosis of benign diseases. This systematic review describes and discusses the literature on urine cytology published since 2010.     

Bleeding Risk in Unruptured and Residual Cerebral Aneurysms – Angiographic Annual Growth Rate in Nineteen Patients

Summary  Whether and when unruptured aneurysms or aneurysmal rests following incomplete surgery result in subsequent bleeding are major concerns for neurosurgeons. By calculating the annual growth rate of aneurysms in long-term follow-up angiography (partly supplemented with MR-imaging and/or MR-angiography), we attempted to determine the surgical indications for these aneurysms. Long-term follow-up angiography ranging from one to 20 years was carried out on five patients whose ruptured aneurysms had been incompletely occluded, six patients with multiple aneurysms, of which the ruptured ones had been completely oblitered at operation and the small unruptured aneurysms, missed or misdiagnosed, and eight patients with unruptured aneurysms which were asymptomatic or symptomatic. The correlation of annual aneurysm growth rate to subsequent bleeding was investigated. Four out of six fast-growing aneurysms with high annual growth rates (more than 8% increase per year) resulted in subsequent bleeding whereas none of the fourteen slow-growing aneurysms with low annual growth rates (less than 8% increase per year) led to bleeding (Fisher's exact test; p<0.01). Hypertension, patient age and aneurysmal location showed no significant correlation to the annual growth rate (Fisher's exact test; p>0.05). This study suggests that aneurysmal rests after incomplete surgery and missed or misdiagnosed multiple or incidental aneurysms which are fast growing have a high possibility of subsequent bleeding and should be operated on as soon as possible.     

ACST-2 – ein Update

Introduction

ACST-2 is a large and simple stream-lined trial which aims to compare both the early hazards and long-term durability of carotid endarterectomy (CEA) versus carotid artery stenting (CAS) in asymptomatic patients with high-grade carotid artery stenosis.

Methods

Patients are eligible for ACST-2 if they have a severe carotid artery stenosis and intervention is clearly indicated, with both CEA and CAS practicable, but where there is substantial uncertainty as to which intervention is best. Collaborating surgeons and stenters may use their usual techniques and any CE-marked devices are permitted.

Results

ACST-2 aims to recruit several thousand patients by 2019. To date, over 1200 patients have been randomised by study collaborators working in 79 centres across 25 countries. Italy is the top recruiting country, followed by the UK and Sweden. Interim blinded analyses reveal a 1?% rate of serious 30-day postprocedure complications (disabling stroke, myocardial infarction or death).

Discussion

ACST-2 is the only trial designed to reliably compare the short-term hazards and long-term benefits of CEA versus CAS in asymptomatic patients, and it complements other carotid trials which compare intervention versus medical management (e.g. SPACE-2). If, as seems likely, these trials show benefit from carotid intervention in addition to contemporary medical management in selected patients, then whether to perform CEA or CAS will remain a highly relevant question, and one only ACST-2 can answer. The English full-text version of this article is available at SpringerLink (under “Supplemental”).     

Update 2016 – Immuntherapie beim Urothelkarzinom

Advanced urothelial carcinoma of the bladder is an aggressive tumor with a poor prognosis. Besides surgical therapy, classical chemotherapy with platinum compounds is the mainstay of advanced bladder cancer treatment. In recent years, immune modulating therapies have come into the focus of clinical trials. This review provides an overview of the biological mechanisms and immuno-oncological drugs that are currently being analyzed in clinical trials as well as established standard therapies.     

Zentrale Notaufnahme – Update 2016

Acute medical care in hospital emergency departments has experienced rapid development in recent years and gained increasing importance not only from a professional medical point of view but also from an economic and health policy perspective. The present article therefore provides an update on the situation of emergency departments in Germany. Care in emergency departments is provided with an increasing tendency to patients of all ages presenting with varying primary symptoms, complaints, illnesses and injury patterns. In the process, patients reach the emergency department by various routes and structural provision. Cross-sectional communication and cooperation, prioritization and organization of emergency management and especially medical staff qualifications increasingly play a decisive role in this process. The range of necessary knowledge and skills far exceeds the scope of prehospital medical emergency care and the working environment differs substantially. In addition to existing structural and economic problems, the latest developments, as well as future proposals for the design of in-hospital emergency medical care in interdisciplinary emergency departments are described.