Influence of cerebrospinal fluid tapping on dynamic equilibrium in suspected hydrocephalus.

Thirty-nine patients aged 21-82 years (mean 62 years) under investigation for suspected acquired hydrocephalus were investigated by dynamic posturography before and 6-8 h after a cerebrospinal fluid tap of 20-40 ml. Dynamic posturography comprises a sensory organization (SO) part in which the platform and visual surround are either stable or referenced to the patient's sway. The eyes are closed or open. In a movement coordination (MC) part the platform makes active movements, thus introducing external disturbances in the procedure. The patients improved their balancing ability in all tests on the sway referenced platform in SO, while MC remained unaffected. It is concluded that dynamic posturography is valuable for dysequilibrium assessment in clinical evaluation of suitable candidates for ventricular shunts in acquired hydrocephalus.

Description of two informative cases of occult spinal dysraphism with remarks on possible traits in the embryogenesis.

Two cases of spinal occult dysraphism are described. The association of a dermoid cyst and ectopic tissue foci of both ecto- and mesodermal origin at the junction zone between lipoma and nervous tissue is argued to support the disjunction theory on lipomeningomyelocele formation.

Nimodipine evoked dilation of cerebral arteries early during the development of late vasospasm in subarachnoid hemorrhage.

In subarachnoid hemorrhage (SAH) late cerebral ischemia may develop without significant visible narrowing of arteries at angiography, but in severe ischemic conditions "vasospasm" invariably seems to be present. The majority of patients with aneurysm rupture develop some degree of vasospasm, whereas relatively few suffer from ultimate brain infarction. The prophylactic use of the calcium antagonist Nimodipine is linked to a beneficial anti-ischemic effect in SAH, although narrowing of large bore arteries still seems to develop despite administration of this drug. Attenuation of vascular spasm, mainly in the arterioles has been implicated as the major mechanism of action, although a neuronprotective effect of Nimodipine has been suggested as well. The present paper presents fragmentary evidence that Nimodipine does elicit a vasoactive response in the cerebral vasculature early during the development of late cerebral vasospasm, and that this response seems closely linked to reversal of attendant ischemic symptoms.

Solitary extradural cavernous hemangiomas in the spinal canal. Report of five cases.

Five cases of solitary extrathecal cavernous hemangioma in the spinal canal are reported. In one case, two coexistent massive cerebral venous medullary malformations were found. The symptomatology and prognosis of extrathecal spinal cavernous hemangiomas are discussed, as is the significance of various diagnostic measures. The patient material further permitted a rough calculation of the incidence of symptomatic extrathecal cavernous hemangiomas in the spinal canal.

Role of transsphenoidal operation in the management of pituitary adenomas with suprasellar extension.

59 consecutive patients with suprasellar extending pituitary adenomas were operated on by the transsphenoidal approach. The suprasellar tumour extension was in 30 cases stage A (Hardy-Wilson), in 18 stage B and in 11 stage C. 14 patients were above 65 years of age and in this latter group 9 cases had large tumours (B or C). 78% of endocrinologically active tumours did not reach the chiasm (stage A) whereas 72% of functionless adenomas compressed the chiasm or grossly the third ventricle. Visual field defects and loss of visual acuity was both present in roughly 90% of stage B and C tumours. Radical surgical removal with regard to suprasellar extension was possible in all but 6 cases. Four of these patients had tumour remnants large enough to require removal by a second intracranial operation. No patient developed visual deterioration post-operatively. Pre-operative visual dysfunction was normalized or markedly improved in more than 90% of the cases. Failure to normalize vision was closely linked to the presence of pale optic discs. Pre-operative hypersecretion was normalized in 70% of the cases. Addition of permanent pituitary insufficiency occurred in three patients.

Transantral repair of cerebrospinal fluid fistulas using bone chips, Tisseel, fascia and plaster of Paris.

Cerebrospinal rhinorrhea is a potentially serious symptom due to the risk of an ascending infection, which may produce a fulminant meningitis. Plaster of Paris has been used to obliterate the sphenoidal sinus and posterior ethmoids in five patients with cerebrospinal rhinorrhea. The fistulas were identified by computed cisternography and repaired by a transantral approach using a microsurgical technique, and bone chips, Tisseel and fascia to seal the fistulas. There have been no postoperative problems or leakage in the three patients with fistulas to the sphenoidal sinus. The cerebrospinal rhinorrhea recurred four and six months after operation in the two patients with fistulas to the posterior ethmoids probably due to surgical, technical problems in one patient and to less support by the plaster of Paris, when the fistulas end in this region. However, the described surgical technique seems to be a good alternative for fistulas to the sphenoidal sinus and should be included in our surgical armamentarium.

Does peroperative external pneumatic leg muscle compression prevent post-operative venous thrombosis in neurosurgery?

Post-operative deep venous thrombosis (DVT) is a frequent and potentially life-threatening complication in neurosurgery. In this field of surgery, with its special demands for exact haemostasis, prophylaxis against deep venous thrombosis with anticoagulant drugs has been utilized only reluctantly. Postoperative pneumatic muscle compression (EPC) has been shown to be effective, although there are several practical considerations involved with this method which limit its clinical applicability. In the present study per-operative EPC was evaluated and was found to provide good protection against DVT in patients with increased risk from this complication. This method has the advantage of being effective, safe, inexpensive and readily practicable.

Facial reflex examination for assessment of trigeminal nerve involvement in pituitary fossa tumours.

Sixteen patients with pituitary fossa tumours with different intrasellar extension have been studied by facial reflex examination, a neurophysiological test for the trigemino-facial pathway. Impaired transmission along the reflex path was shown in patients with proved encroachments on the flexible walls of the cavernous sinuses, but with no tumour spread to the brain stem and facial nerve. The findings were consistent with a subclinical involvement of the first trigeminal division. Tumour removal resulted in recovery in nerve conduction. It is concluded that facial reflex examination is a valuable test for detecting cavernous sinus involvement in pituitary fossa tumours.

Mucocele of the sphenoidal sinus.

Mucocele of the sphenoidal sinus is a rare lesion often mistaken for a pituitary tumour. A case first misdiagnosed as pituitary tumour is described. Additional radiography including CT findings led to the correct diagnosis. The treatment of sphenoidal mucoceles is surgical. The sublabial trans-septal route has proved to be an excellent approach.

Early post-operative growth hormone levels predict the result of transsphenoidal tumour removal in acromegaly.

Serum human growth hormone (hGH) measurements were performed during transsphenoidal microsurgery for acromegaly and in the early period afterwards. There were 14 patients of which 2 were operated on twice. In 11 patients (2 patients at reoperation) the serum hGH concentration was normalized to less than 5 micrograms/l within 3 h after completion of surgery. On five occasions only partial restoration of the hGH values was obtained and additional treatment was given in 2 patients by successful re-operation. The early post-operative hGH concentrations were consistent with the clinical evaluation of the patients and the hGH concentrations during follow-up for an average of 27 months. We conclude that early post-operative serum hGH measurement is of value for evaluation of the efficiency of the tumour removal and the need for further treatment.