[Familial brain abscess as a complication of hereditary hemorrhagic telangiectasia]. / Hereditaer haemorrhagiás teleangiectasia szövódményeként kialakult agytályog családi halmozódása.

The hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber disease) is an inherited autosomal dominant disease with angiodysplasia of the skin, mucosa, parenchymal organs, and it can affect the central nervous system. In 40% of the cases neurological complications, most frequently intracerebral abscesses occur. In this study, the case history of a patient with central nervous system manifestation of hereditary hemorrhagic telangiectasia showing familiar aggregation of brain abscess will be presented. A young male patient was admitted to Neurological Department because of his first epileptic seizure and progressive right hemispheric symptoms. His examinations showed frontal abscess, which was surgically removed. The frequent nose-bleeding of the patient and recurrent brain abscess in his brother's history provided the possibility of hereditary hemorrhagic telangiectasia. The background of brain abscess were multiple pulmonary arteriovenous malformation, which were embolized by repeated angiography. Familiar brain abscess is very rare. However, in the case of brain abscess especially with familiarity diagnosis of the Rendu-Osler-Weber disease should be considered.

Complete removal of colloid cyst via CT-guided stereotactic biportal neuroendoscopy.

Four patients harbouring a colloid cyst of the 3rd ventricle were operated on endoscopically. With the "classical" monoportal technique, through a precoronal burr hole only partial removal could be achieved in the first case. As the crucial point of the procedure is the safe dissection of the cyst from the thela chorioidea and from the internal cerebral veins, adequate control of the posterior rim of the foramen of Monro and the roof of the 3rd ventricle is mandatory. Accordingly in other three cases a CT-guided biportal endoscopic technique was applied, which permitted radical removal of the entire cyst with maximum safety. CT-guidance is essential for optimal planning after careful study of the individual anatomy. In this way the rigid scopes are moved exclusively along their own axes throughout the procedure, the resulting brain damage thereby being minimal. With regard to all circumstances of the procedure, the use of flexible endoscopes appears to be inappropriate and biportal endoscopy offers itself as the method of choice.

Biportal endoscopic removal of a primary intraventricular hematoma: case report.

Primary intraventricular hematomas account for approximately 6% of all intracerebral hematomas. If the clot blocks cerebrospinal fluid (CSF) pathways, surgical intervention, which may be of different types, can be life-saving. In the case reported here, after careful preoperative planning the use of two rigid endoscopes permitted the removal of most of the intraventricular clot and restoration of CSF circulation by creation of a 3rd ventriculostomy within the same procedure and no later treatment was necessary. Repeated CT scans proved that only a small portion of the intraventricular clot remained in the ventricular system. The ventricular size normalised, and the patency of the artificial hole in the floor of the 3rd ventricle was demonstrated both by the rapidly improving clinical picture of the patient and by flow-sensitive MRI studies. For individuals who suffer primary intraventricular hemorrhage and later develop occlusive hydrocephalus, endoscopic removal of the clot and 3rd ventriculostomy might offer a more adequate treatment option than external ventricular drainage.

Initial clinical experience with a combined pulsed holmium-neodymium-YAG laser in minimally invasive neurosurgery.

Various biophysical features of the laser beam have already been utilized in clinical neurosurgery. However, the application of this therapeutic modality has by no means been overexploited. The history of laser application in neurosurgery has shown that there is no universal laser system capable of performing all surgical tasks in a suitable manner. The best results in traditional neurosurgery were achieved with instruments combining various wavelengths, such as the CO2 and neodymium-YAG lasers. A pulsed holmium-YAG and neodymium-YAG (Ho:YAG and Nd:YAG) combined laser have been recently developed to meet the special requirements of minimally invasive neurosurgery. The system consists of a compact double-crystal single-head solid-state laser system generating 2 different wavelengths (Ho:YAG 2.08 microns and Nd:YAG 1.05 microns), selected for their capabilities of efficient coagulation and ablation. The two wavelengths are coupled into a common flexible optical fiber, which allows endoscopic application. The wavelengths can act simultaneously or separately without any interchange of the instruments. The system was employed first for experimental and subsequently for clinical purposes, primarily for endoscopic operations. In this work the initial clinical experience is reported. The excellent haemostatic properties of the Nd:YAG laser and the ablative properties of the Ho:YAG laser were confirmed. It was concluded that simultaneous application of the two laser modalities within one flexible fiber offers new perspectives in tissue handling in endoscopic neurosurgery and as in open microsurgery.

Transcranial Doppler-determined pulsatility index in the evaluation of endoscopic third ventriculostomy (preliminary data).

OBJECTIVE: Endoscopic 3rd ventriculostomy has become the method of choice in the management of occlusive hydrocephalus. The treatment is accompanied by significantly less peri-operative complications than the cerebrospinal fluid shunting procedures previously employed. Close surveillance of patients, however, is necessary to avoid the consequences of raised intracranial pressure that may develop in case of obstruction of the artificial outlet of the 3rd ventricle. The aim of this study was to confirm the value of transcranial Doppler-determined pulsatility index (PI) in the assessment of the patency of endoscopic 3rd ventriculostomy and to elucidate its usefulness in early postoperative recognition of increased intracranial pressure. METHODS: In twenty-two patients suffering from occlusive hydrocephalus, transcranial Doppler sonography (TCD) was performed before, immediately after, and five days after endoscopic fenestration of the floor of the 3rd ventricle. PI was defined with fast Fourier transformation. Mean PI values were determined in both middle cerebral arteries (MCA), over five cardiac cycles. RESULTS: In nineteen cases, PI values showed a significant decrease immediately as well as five days after the intervention as compared to the pre-operative values, and flow-sensitive MRI confirmed the patency of the fenestration in all cases. In one patient the operation failed to produce an effective diversion of cerebrospinal fluid as shown by flow-sensitive MRI, and the pulsatility index was unchanged. In two patients, a significant immediate postfenestration drop in PI was followed by a recurrence of PI to pre-operative levels without any clinical deterioration. CONCLUSIONS: Preliminary results suggest that the transcranial Doppler-determined pulsatility index is a useful non-invasive tool for the evaluation of the patency of the fenestration in the early follow-up of patients who underwent endoscopic third ventriculostomy.

Biportal endoscopic management of third ventricle tumors in patients with occlusive hydrocephalus: technical note.

OBJECTIVE: To present the feasibility and advantages of the biportal endoscopic management of posterior third ventricle tumors. As a result of recent developments in neuroendoscopy, classical third ventriculostomy has become a standard single burr hole procedure and a real alternative to shunting in the treatment of occlusive hydrocephalus. In patients with third ventricle tumors occluding the aqueduct, the acute development of hydrocephalus may often precede debilitating focal symptoms and signs. Forty percent of those tumors are radiosensitive, rendering craniotomy unnecessary. The goal of primary management is the alleviation of raised intracranial pressure and determination of the histological nature of the tumor. Cerebrospinal fluid shunting and the performance of a computed tomography- or magnetic resonance imaging-guided biopsy are generally suggested as the methods of choice. METHODS: Three patients with posterior third ventricle tumors and acute hydrocephalus were treated in one session by computed tomography-guided endoscopic third ventriculostomy and endoscopic tumor biopsy was performed by means of two rigid ventriculoscopes. RESULTS: Ventriculostomy was performed in three patients, and tumor biopsy was performed in two patients. The maximum 40-minute operation did not involve mortality or morbidity. Histological findings were established in all patients. In two patients with malignant infiltrative tumors, postoperative radiotherapy was used; in one patient with a small cavernoma, no further measures were taken. At the 6-month follow-up, flow-sensitive magnetic resonance imaging confirmed ventriculostomy patency in all patients. CONCLUSION: The biportal endoscopic approach allowed independent visual control of both procedures, safe passages of the ventriculoscopes via the narrow foramen of Monro, and facile control of the intracranial pressure in the ventricles via the available four irrigation channels during the performance of tumor biopsy and fenestration of the floor of the third ventricle. In selected patients with infiltrating posterior third ventricle tumors, this procedure and postoperative radiotherapy may be an alternative to direct surgery or to shunting and performance of image-guided biopsy.