Radiation-induced brain tumours in nevoid basal cell carcinoma syndrome: implications for treatment and surveillance.

INTRODUCTION: We report two cases of radiation-induced intracranial tumours after treatment for medulloblastoma presenting in children with nevoid basal cell carcinoma syndrome. DISCUSSION: These cases illustrate the need for judicious use of post-operative radiotherapy as secondary tumors are commonly reported. This is particularly important as the initial tumour in this cohort is of the 'less aggressive' desmoplastic subtype.

New proposals for training in neurosurgery.

The rapidly evolving changes in working patterns, career structure and the regulation of training of doctors have provided an ideal opportunity for proposals to improve the programme for the training of neurosurgeons. The Education and Training Committee of the Society of British Neurological Surgeons (D.G. Hardy, A. J. W. Steers, N. T. Gurusinghe, P. M. Foy, P. van Hille, R. A. Cowie, H. A. Crockard, O. Sparrow and S. Burn) has, in recent months, worked closely with the Specialist Advisory Committee (SAC) in neurosurgery, Department of Health (Modernizing Medical Careers Group, H. A. Crockard, A. Havers, T. Hobbs) and colleagues from the major neuroscience specialties to develop a new programme based on a 'Common Stem' approach. This article describes the principles of the programme. The proposals have received approval by the Council of the SBNS, the Presidents of the four Surgical Royal Colleges and the Senate of Surgery.

Cranio-spinal enterogenous cysts: clinico-radiological analysis in a series of ten cases.

Enterogenous cysts are rare congenital lesions resulting from dysgenesis during the third embryonic week at the time of notochord development and the transitory existence of the neurenteric canal. Enterogenous cysts are usually lined by mucus secreting epithelium resembling that of the gastrointestinal tract. The inclusion of the endodermal elements in the spinal canal may produce extradural, intradural extramedullary or intradural intramedullary cystic lesions. The endodermal inclusions producing cysts in the intracranial compartment are extremely rare, especially in the supratentorial region. Plain X-rays may show concomitant cranio-spinal anomalies. However, CT and MRI scans show better definition and characterisation. Total excision is the procedure of choice in these benign cysts with favourable long term prognosis. Approximately 100 histologically proven cases have been described, with a few exceptions, as isolated case reports the authors report a detailed analysis of the clinico-radiological aspects of a series of ten patients with cranio-spinal enterogenous cysts with a review of the literature.

Multiple primary cerebral hydatid cysts: case report.

The authors report the case of a patient with primary multiple cerebral hydatid cysts emphasizing the role played by MRI in planning the surgical approach. The indications for medical treatment of such lesions are also discussed.

Intracranial angiolipoma: report of two cases.

Intracranial tumours composed of adipose tissue and abnormal blood vessels are rarely recognized. We report two such cases; one showed the radiological and histological appearances of a combined lipoma and an arteriovenous malformation, the other the appearances of a lipoma with a prominent capillary component. Computed tomography did not give any indication of their vascular nature, but surgery was complicated by intra- and postoperative haemorrhage.

Compression of the C-2 root by a rare anomalous ectatic vertebral artery. Case report.

The authors report a symptomatic congenitally anomalous ectatic vertebral artery not passing through the transverse foramen of the atlas (C-1), but instead piercing the dura mater below the posterior arch of the C-1 in the atlantoaxial (C1-2) interlaminar space. This occurrence is exceptionally rare, but in this case it was uniquely associated with occipital neuralgia due to vascular compression of the C-2 root. Microvascular decompression was curative. Neuroradiological and surgical findings are presented and their implications discussed.

Ossification of the ligamentum flavum in a Caucasian: case report.

Ossification of the ligamenta flava (OLF) and posterior longitudinal ligament (OPLL) of the spine causing spinal cord compression is described mainly in Japanese patients and is often termed as 'Japanese disease'. We are reporting a case of OLF of the thoracic spine seen in a male Caucasian who presented with an intractable intercostal pain. This is the first case report of OLF in a Caucasian.

Intraparenchymatous schwannoma of the cerebellum.

Intraparenchymatous schwannomas of the central nervous system are rare. In decreasing order of frequency they are found in the spinal cord, cerebral hemispheres, brainstem and cerebellum. So far, only six such tumours have been reported in the cerebellum. A male predominance and early onset of symptoms are salient features. A case of a 73-year-old Caucasian female with an intraparenchymatous schwannoma of the right cerebellar hemisphere which extended into the brainstem is reported. A complete cure followed surgical removal of the tumour. The preoperative clinical and radiological diagnosis was that of a cerebellar astrocytoma.

Cerebral berry aneurysms in identical twins: a case report.

A pair of identical twins in whom cerebral berry aneurysms were found is reported. One presented with epilepsy, and the aneurysm was discovered incidentally. The other presented with a spontaneous bleed, which was fatal.

Cerebral infarction due to Aspergillus arteritis following glioma surgery.

Cerebral infarction due to fungal arteritis is an uncommon complication of neurosurgical operations and adjuvant immunosuppressive therapy, including long-term steroids. If unrecognized, the neurological deterioration which ensues may be mistreated by increasing the dose of steroids. A case of a 38-year-old Caucasian male who had no obvious immune deficiency or fungal infection prior to a craniotomy for cerebral tumour is described in whom perioperative aspergillus infection resulted in cerebral arteritis and extensive cerebral infarction with a fatal outcome. Long-term steroid therapy used in the management of cerebral tumours may carry an increased risk of systemic or cerebral fungal infection. The possibility of cerebral mycosis (arteritis) and dangers of its non-recognition are highlighted.

A low cost modification of an old Leksell stereotactic frame to allow CT-guided stereotaxy.

The high cost of commercial CT-compatible stereotactic frames has restricted the availability of CT-guided stereotaxy for many neurosurgical centres. However, many of these centres do possess the standard stereotactic frames for projection radiography, of which the old type Leksell frame is probably the most common. We have devised a simple and low-cost modification to an old Leksell frame to allow CT-guided stereotaxy. The nature of the modifications allow complete freedom of positioning of the frame relative to the CT scanner and coordinate transformations can be performed simply and effectively. The modified frame has been used successfully for some 18 months and the modification has now been performed at two centres in the North West Regional Health Authority. We hope this modification will allow many other centres to embark on CT-guided stereotaxy.

Chlormethiazole in the management of post-craniotomy seizures.

Epilepsy is an important problem in the period immediately following intracranial surgery. Rapid control of seizures is important to prevent damage to cerebral neuronal function. A method of managing epilepsy using intravenous chlormethiazole is reported. This regimen has proved to be safe and rapidly effective in the control of post-operative seizures.

The value of computerized tomography in aneurysmal subarachnoid hemorrhage. The concept of the CT score.

Of 256 patients with aneurysmal subarachnoid hemorrhage, 131 underwent computerized tomographic (CT) scanning within 7 days of the ictus. These scans were analyzed in order to assess the quantity of blood in the main subarachnoid cisterns and cerebral fissures. The method of quantification used recognized the horizontal and vertical components of the largest clot visible on the CT scan and expressed this as the "CT score." Angiographic vasospasm was assessed and graded, based on reduction in the caliber of the major cerebral vessels. The CT score was then compared to 1) the incidence of angiographic vasospasm, 2) the clinical course, and 3) the eventual outcome. Of the patients who showed no blood on the initial CT scan, 87% were admitted in good clinical grades, whereas among patients with higher CT scores the number admitted in poor clinical grades increased. The degree of angiographic vasospasm did not relate as closely as the CT score to the clinical grade on admission or to the subsequent clinical course. The final outcome was assessed on follow-up review, and those acquiring neurological deficits from ischemic neurological dysfunction (IND) were identified. Ninety percent of patients with no blood on the CT scan (CT score 0) had a good outcome, while 5% sustained the effects of IND. The incidence of IND gradually increased with a rise in the CT score until, with scores of 8 and above, 90% of patients suffered the ill effects of IND. The CT score proved to be a simple yet accurate prognostic indicator of the outcome of IND.