Klinikum Stuttgart

Stuttgart Mühlhausen, Germany

Klinikum Stuttgart

Stuttgart Mühlhausen, Germany
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Kuemmerle-Deschner J.B.,University Hospital of Tuebingen | Koitschev A.,Klinikum Stuttgart | Ummenhofer K.,Martin Luther University of Halle Wittenberg | Hansmann S.,University Hospital of Tuebingen | And 5 more authors.
Arthritis and Rheumatism | Year: 2013

Objective Muckle-Wells syndrome (MWS) is an inherited autoinflammatory disease characterized by fevers, rashes, arthralgia, conjunctivitis, and sensorineural hearing loss. In MWS, NLRP3 gene mutations are associated with excessive interleukin-1 release. The aims of this study were to determine the otologic characteristics of MWS, define trajectories of hearing loss, and explore the association with distinct NLRP3 genotypes. Methods A prospective observational cohort study of children and adults diagnosed as having MWS was conducted at a single center. NLRP3 gene mutations were determined. Patients underwent standardized clinical, laboratory, and otologic assessments, including pure tone audiometry, vestibular organ testing, and tinnitus evaluation. Trajectories of hearing loss were defined for each genotype. The genotype-specific risk of progression of hearing loss was determined. Results A total of 33 patients ages 3-75 years who were members of 5 families with 4 different NLRP3 gene mutations were included. The majority of patients (67%) experienced bilateral sensorineural hearing loss. Even in cases of profound hearing loss vestibular reactivity remained normal. Fourteen adult patients reported nondebilitating tinnitus. Overall, hearing impairment progressed with age. Patients with the T348M mutation were at highest risk of rapid progression of sensorineural hearing loss. Conclusion Patients with MWS are at risk of developing progressive sensorineural hearing loss without vestibular involvement. Hearing impairment starts at high frequencies and can subsequently progress to profound hearing loss. Progression is age dependent. Patients with different NLRP3 mutations had distinctly different trajectories of hearing loss, suggesting a mutation-specific risk that should be considered when making treatment decisions. © 2013 by the American College of Rheumatology.

Aguilar-Perez M.,Klinikum Stuttgart | Kurre W.,Klinikum Stuttgart | Fischer S.,Klinikum Stuttgart | Henkes H.,Klinikum Stuttgart
American Journal of Neuroradiology | Year: 2014

BACKGROUND AND PURPOSE: The pCONus is a new stentlike self-expanding nitinol implant with 4 distal petals, which is fully retrievable and electrolytically detachable. The distal end is implanted inside the aneurysm at the neck. The shaft is anchored in the parent vessel. In selected wide-neck bifurcation aneurysms, the pCONus was used to assist coiling. The device was evaluated for its safety and efficacy. MATERIAL AND METHODS: Twenty-eight patients with 28 wide-neck aneurysms (9 recently ruptured) were treated with pCONusassisted coiling at the discretion of the operator. Other treatment options were considered but were discarded due to anticipated difficulties. Technical issues, immediate posttreatment angiographic findings, clinical outcome, and follow-up imaging were assessed. RESULTS: There were 11 MCA, 7 anterior communicating artery, 1 posterior cerebral artery, 1 A2, and 8 basilar artery aneurysms. Insertion and deployment of the pCONus and subsequent coiling were possible in all cases. There were no clinically evident complications associated with the use of the device. Initial anatomic outcome showed 8 complete occlusions, 9 neck remnants, and 11 incomplete occlusions. Neurologic status remained unchanged at follow-up. Angiographic controls were obtained in 22 patients (mean, 7.5 months). Of these, 13 had complete occlusion, 9 showed improvement, and 7 were unchanged. Four died from SAH sequelae or other diseases, and 2 have not yet undergone follow-up. No intimal hyperplasia was observed. CONCLUSIONS: The pCONus facilitates coil occlusion of unruptured and ruptured wide-neck bifurcation aneurysms. The device can be deployed safely. Coil retention is sufficient to protect the efferent vessels. So far, no intimal hyperplasia in the shaft has been observed.

Coburger J.,University of Ulm | Musahl C.,Klinikum Stuttgart | Henkes H.,Klinikum Stuttgart | Horvath-Rizea D.,Klinikum Stuttgart | And 3 more authors.
Neurosurgical Review | Year: 2013

Navigated transcranial magnetic stimulation (nTMS) is a novel tool for preoperative functional mapping. It detects eloquent cortical areas directly, comparable to intraoperative direct cortical stimulation (DCS). The aim of this study was to evaluate the advantage of nTMS in comparison with functional magnetic resonance imaging (fMRI) in the clinical setting. Special focus was placed on accuracy of motor cortex localization in patients with rolandic lesions. Thirty consecutive patients were enrolled in the study. All patients received an fMRI and nTMS examination preoperatively. Feasibility of the technique and spatial resolution of upper and lower extremity cortical mapping were compared with fMRI. Consistency of preoperative mapping with intraoperative DCS was assessed via the neuronavigation system. nTMS was feasible in all 30 patients. fMRI was impossible in 7 out of 30 patients with special clinical conditions, pediatric patients, central vascular lesions, or compliance issues. The mean accuracy to localize motor cortex of nTMS was higher than in fMRI. In the subgroup of intrinsic tumors, nTMS produced statistically significant higher accuracy scores of the lower extremity localization than fMRI. fMRI failed to localize hand or leg areas in 6 out of 23 cases. Using nTMS, a preoperative localization of the central sulcus was possible in all patients. Verification of nTMS motor cortex localization with DCS was achieved in all cases. The fMRI localization of the hand area proved to be postcentral in one case. nTMS has fewer restrictions for preoperative functional mapping than fMRI and requires only a limited level of compliance. nTMS scores higher on the accuracy scale than fMRI. nTMS represents a highly valuable supplement for the preoperative functional planning in the clinical routine. © 2012 Springer-Verlag.

Kasenda B.,Klinikum Stuttgart | Loeffler J.,Massachusetts General Hospital | Illerhaus G.,Klinikum Stuttgart | Ferreri A.J.M.,San Raffaele Scientific Institute | And 2 more authors.
Blood | Year: 2016

A 63-year-old woman presented with progressive dizziness and headaches. A brain magnetic resonance imaging (MRI) revealed a 3 3 4 cm contrast enhancing single mass in the right parietal lobe; stereotactic biopsy of themass revealed aCD20-positive diffuse large B-cell lymphoma (DLBCL). Body fluorodeoxyglucose-positron emission tomography scan and bone marrow biopsy were negative. The patient had no other health issues. She had good performance status when starting treatment with the combination of rituximab, high-dose methotrexate (HD-MTX) (3.5 g/m2), and high-dose cytarabine (HD-Ara-C) (2 3 2 g/m2). After 4 courses, she achieved a partial radiographic response. After 2 more courses, she achieved a complete radiographic response. After achieving complete response (CR), myeloablative, nonmyeloablative chemotherapy, or whole brain radiotherapy (WBRT) were considered as consolidative treatments to reduce the risk of relapse. © 2016 by The American Society of Hematology.

Burgy M.,Klinikum Stuttgart
Nervenheilkunde | Year: 2012

The recent developments in social psychiatry with de-hospitalisation, i.e. the move away from hospital care for people with chronic mental disorder, the closure of long-term hospital units and the development of community psychiatric services, have reached a provisional conclusion. The successes of these developments must not, however, deceive us into believing that all there are no more problems to be overcome. We have not succeeded, for example, in completely moving away from hospital care for the elderly with chronic mental disorder. These patients have in the main simply been transferred into care homes which are further away from the patients' own homes and where the care is provided by less well qualified staff. There is also a group of younger people with chronic mental health problems which is characterised by a rising number of in-patient admissions to hospital as well as increased rates of suicidal tendencies, criminality and readiness to resort to violence. It is becoming clear that further developments in social psychiatry will above all have to be aimed at providing a closer and more effective integration of community and hospital psychiatric services than has been achieved so far. © Schattauer 2012.

Palliative medicine frequently faces the problem of suitable drug application since many palliative care patients suffer difficulties in swallowing and i.v. application often implicates strong physical stress during the last phase of life. Hence, in palliative medicine the s.c. application of drugs is a suitable alternative. The major difficulty is that only a few drugs are approved for s.c. application. Therefore, it is necessary to rely on own or published experience. This article summarises the possible s.c. medications for the most common symptoms in palliative care in form of a drug standard. This standard helps physicians regarding therapy decisions and it serves as reference text for the nursing staff.

Musahl C.,Klinikum Stuttgart | Henkes H.,University of Duisburg - Essen | Coburger J.,Klinikum Stuttgart | Hopf N.,Klinikum Stuttgart
Neurosurgery | Year: 2011

Background: Cerebral vasospasm (CV) is a potentially disastrous consequence of subarachnoid hemorrhage despite medical treatment. Nimodipine is a potent drug for vessel relaxation, but side effects may preclude a sufficient dose. Objective: To explore whether continuous local intra-arterial nimodipine administration (CLINA) can reverse vasospasm and prevent delayed ischemic neurological deficit. Methods: Six consecutive subarachnoid hemorrhage patients (5 women; mean age, 47.2 years) with severe CV despite maximum medical therapy underwent CLINA within 2 hours after the onset of clinical symptoms. After anticoagulation, microcatheters were inserted distally in the concerning supra-aortic vessels. Glyceryl trinitrate injection (2 mg) was followed by CLINA (nimodipine 0.4 mg/h for 70-147 hours). Duration of CLINA was determined by neurological status, transcranial Doppler sonography, and partial tissue oxygen pressure values. Results: In all patients, neurological deficits improved or partial tissue oxygen pressure values returned to normal and transcranial Doppler sonography confirmed a reduced blood flow velocity within 12 hours. Magnetic resonance imaging showed no ischemic lesion caused by CV. Neurological outcome was good (modified Rankin Scale score, 0-2) in 3 patients, whereas 1 patient had a moderate clinical outcome (modified Rankin Scale score, 3-4) and 2 patients had a poor outcome (modified Rankin Scale score, 5) because of the SAH. Conclusion: Preliminary data show that CLINA is a straightforward, effective, and safe option for patients with severe CV refractory to medical therapy. Dilation of spastic arteries starts within a few hours and is lasting. Indication for CLINA is peripheral and diffuse CV at any location. Copyright © 2011 by the Congress of Neurological Surgeons.

Kniesel B.,Klinikum Stuttgart | Huth J.,Sportklinik Stuttgart | Bauer G.,Sportklinik Stuttgart | Mauch F.,Sportklinik Stuttgart
Archives of Orthopaedic and Trauma Surgery | Year: 2014

Purpose: In recalcitrant epicondylitis innumerable operative techniques have been published, nevertheless a certain percentage of patients remains symptomatic after operative treatment. We developed an individual, systematic diagnostic pathway including arthroscopic assessment of elbow stability to identify the optimal and respectively less invasive therapy.Methods: We so far included 40 patients with recalcitrant lateral epicondylitis (mean age 46 ± 11). 5 patients had previous surgery. In all patients, we did an elbow arthroscopy and a systematic arthroscopic stability testing. 25 patients were treated exclusively arthroscopically once instability was excluded. In 13 patients with slight instability, we did an open debridement of the lateral tendon complex and local refixation. Two patients with severe instability were treated with open debridement and additional stabilization of the LUCL with a trizeps graft. With a minimum follow-up of 1 year, we assessed the DASH score and subjective patient satisfaction.Results: Mean follow-up was 24 ± 12 months, mean duration of symptoms before surgery was 19 ± 18 months. The mean DASH score at follow-up was 22 ± 19.36 patients reported symptoms improvement, 34 patients would repeat surgery given the same situation; in 30 cases, patients expectations had been fulfilled. We did not observe any intraoperative complications or infections. One patient developed joint stiffness requiring reoperation.Conclusion: Using a systematic diagnostic pathway including assessment of elbow stability and consecutive individualized, respectively, less invasive surgical procedure we acquired high patients satisfaction and good clinical outcome with a low complication rate.Level of evidence: Level III. © 2014, Springer-Verlag Berlin Heidelberg.

Kurre W.,Klinikum Stuttgart | Aguilar-Perez M.,Klinikum Stuttgart | Niehaus L.,Klinikum Schloss Winnenden | Fischer S.,Klinikum Stuttgart | Henkes H.,Klinikum Stuttgart
Cerebrovascular Diseases | Year: 2013

Background: There is uncertainty about the role of endovascular recanalization procedures for the treatment of acute ischemic stroke in patients aged ≥80 years. Therefore, careful patient selection is mandatory. Our aim was to find valid predictors of clinical outcome after mechanical thrombectomy (mTE) based on the sparse information available in the emergency setting. Methods: We included consecutive patients aged ≥80 years treated by mTE for anterior circulation thromboembolic vessel occlusion in our department between January 2008 and January 2013. Successful recanalization was defined as a thrombolysis in cerebral infarction (TICI) score of 2b or 3. The rates of parenchymal hemorrhage types I (PHI) and II (PHII) according to the ECASS definition and the rate of focal and diffuse subarachnoid hemorrhage (SAH) were reported. A modified Ranking scale (mRS) score of 0-2 at 90 days was defined as a favorable outcome. We evaluated the influence of gender, smoking habits, atrial fibrillation, diabetes, hypertension, hyperlipidemia, coronary artery and peripheral artery disease, National Institutes of Health Stroke Scale (NIHSS) score, Totaled Health Risks in Vascular Events (THRIVE) score, Alberta Stroke Program Early CT Score (ASPECTS), and duration of symptoms on favorable outcome. Significant predictors were then included in a stepwise logistic regression analysis. Odds ratios (OR), 95% confidence intervals (CI), and receiver operating characteristics (ROC) curves were calculated. p < 0.05 was considered statistically significant. Results: In the defined period, we treated 109 patients aged ≥80 years with 116 occluded anterior circulation target vessels. Successful recanalization was achieved in 87.9% of the targets. The rates of PHI, PHII, and focal and diffuse SAH were 6.4, 5.5, 12.8, and 7.3%, with an overlap between PH and SAH. The combined rate of PHII and/or diffuse SAH was 9.2%. Despite good recanalization rates and reasonable rates of hemorrhage, only 19 patients (17.4%) were functionally independent at 90 days. An additional 12 patients (11.0%) suffered from moderate disability (mRS score 3), 26 (23.9%) were severely disabled (mRS score 4-5) and 52 (47.7%) were deceased. NIHSS, ASPECTS, and THRIVE scores significantly predicted a favorable outcome. Stepwise logistic regression identified NIHSS (OR 0.89; 95% CI 0.82-0.96; p = 0.009) and ASPECTS (OR 2.27; 95% CI 1.28-4.02; p = 0.005) as independent predictors. The ROC area was 0.81. Conclusion: ASPECTS and NIHSS were independent predictors of a favorable outcome in patients aged ≥80 years after mTE for anterior circulation large vessel occlusion and may support decision making with regard to the treatment modality. Since the chances of gaining functional independence are limited, careful consideration of each individual case is mandatory. Further studies comparing endovascular and standard treatment in octogenarians are warranted. © 2013 S. Karger AG, Basel.

Sittel C.,Klinikum Stuttgart
Laryngo- Rhino- Otologie | Year: 2014

Idiopathic subglottic stenosis is causing a narrowing of the central airway at the laryngotracheal junction. Etiology is remaining unclear at large. There is a marked preponderance for women in the fertile age, an association to estrogene or progesterone metabolism remains doubtful. Suggested treatment varies from repeated endoscopic interventions to primary open resection. Therapy selection in this heterogeneous condition should be based on the individual patient situation as well as surgeon's expertise. This complex entity is prone to complications and should preferably be managed in a referral center. © Georg Thieme Verlag KG Stuttgart.

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