Ocular manifestations of sphenoid mucoceles: clinical features and neurosurgical management of three cases and review of the literature.

BACKGROUND: Sphenoid mucoceles (SMCs) are unusual lesions, with about 130 cases reported in the literature. Although benign, they may involve the orbit and cause acute restrictive ophthalmoplegia, proptosis, and reduced visual acuity. METHODS AND RESULTS: We present three cases (1 male, 2 females, aged 35, 36, and 46 years) of orbital involvement with acute decreased visual acuity by SMC. The lesions were promptly excised via a transnasal approach to decompress the optic nerve. After the decompression, the patients recovered completely. CONCLUSION: We believe that immediate surgical drainage of the SMC and prolonged antibiotic therapy are necessary and resulted in recovery of visual acuity. Prompt microsurgical transsphenoidal decompression is simple, effective, safe, and is necessary for avoiding persistent visual loss. Antibiotic therapy alone usually results in a poor outcome. We discuss the etiology, clinical manifestations, and management of this rare condition in the light of 130 other cases in the literature.

Gliomatosis cerebri: intra vitam stereotactic determination in two cases and review of the literature.

Gliomatosis cerebri (GC) is an infiltrative neoplastic process that is diffusely distributed through neural structures, whose anatomical configuration remains intact. Most of the cases with GC reported in the literature were diagnosed at autopsy (101/110, 92%). We report two cases of GC in a 42-year-old woman and a 65-year-old man. The diagnosis was confirmed neuropathologically after MRI-guided stereoetactic biopsy. External radiation therapy was performed and led to a complete recovery of all clinical signs. Follow-up examinations 17 and 21 months after diagnosis showed permanent reversal of all clinical and radiological signs. MRI should be used as a primary imaging study in the evaluation of GC and for the determination of the target points for stereotactic biopsy. We discuss the aetiology, clinical manifestation, difficulties of intra vitam diagnosis, and management of this rare condition in the light of other 110 (101 postmortem and nine intra vitam) reported cases of GC in the literature.

The value of intraoperative angiography in surgery of intracranial aneurysms: a prospective study in 126 patients.

The value of intraoperative digital subtraction angiography in surgery for intracranial aneurysms, the benefits and cost-effectiveness are a matter of discussion. We prospectively studied 126 patients with 144 aneurysms, most on the anterior intracranial circulation, who underwent clipping and intraoperative angiography. Follow-up was 28.4 +/- 13.1 months. We tried to work out the indications for intraoperative angiography of the anterior circulation and its cost-effectiveness. In 10.3 % of patients (9 % per aneurysm) unexpected findings were shown by intraoperative angiography: inadequately clipped aneurysms in 10 (7.9 %), a completely unclipped aneurysm in one (0.8 %) and occluded major arteries in two (1.6 %). A broad neck was a variable of statistical significance for inadequate clipping or stenosis or occlusion of an adjacent vessel. There was a strong trend for aneurysms more than 15 mm in diameter to be "risky". Their site was not a predictive factor. We believe that intraoperative angiography is indicated in surgery not only on large and giant aneurysms, but also broad-based aneurysms of the anterior cerebral circulation regardless of their size. It is cost-effective compared to postoperative angiography. The rate of stroke in our hands was 0.8%.

[Acupuncture and other forms of treatment for patients with chronic back pain]. / Akupuntur und andere Therapieformen beim Patienten mit chronischen Wirbelsäulenschmerzen.

As in all pain sites, one has to distinguish between acute and chronic pain in spinal pain syndromes. The treatment of chronic spinal pain is dominated by non-operative procedures. There are three main procedures in this field of treatment: the manual medicine, the therapeutic application of local anesthetics and acupuncture. By manual techniques the pain-producing spinal structures can be recognized and these techniques offer at the same time sufficient treatment options to the patients. Therefore, manual therapeutic strategies are applied at first in a treatment session followed by the therapeutical application of local anesthetics. With this treatment the pain-producing spinal sites are directly influenced with the aim of blocking the nociceptors. Acupuncture is the last step of the treatment cascade in out patients in any case, because acupuncture does not only serve as treatment option for pain relief, but also and even more so has an harmonizing effect upon physical and psychological disturbances. It is absolutely necessary for the patient to lie down for 25 to 30 minutes to reach these goals. More invasive methods are offered to patients unsuccessfully treated by the described methods. These are: X-ray conducted periradicular infiltration, epidural blockades with local anesthetics and steroids, hiatus sacralis blockade, percutaneous radiofrequency denervation of the facet joint and percutaneous lumbar radiofrequency sympathicotomy. The indications for these treatment modalities are discussed as well as technical details regarding the performance. Disc herniation with radicular symptoms, spinal canal stenosis, cervical stenotic myelopathy and degenerative spinal instability may represent indications for surgical intervention. The symptomatology of these diseases is described. The indications for the individual cases and circumstances are discussed. Lastly, the various operative techniques are also described shortly.

Posterior cervical foraminotomy. A follow-up study of 67 surgically treated patients with compressive radiculopathy.

A retrospective study was conducted on 67 patients undergoing posterior cervical foraminotomy (PCF) for unilateral intraforaminal soft and hard disc disease. Neurologic impairment, employment, and severity of associated signs were assessed preoperatively and at a 3.1-year average follow-up (range, 1.5-7 years). Diminution or complete disappearance of radicular symptoms was observed in 62 cases (93%), 3 months to 3 years after surgery. Minimal neurologic deficits persisted in 5 cases (7%). Neck pain improved in 62 cases, remained unchanged in three, and progressed in two cases with severe preoperative deficits. Fifty-three patients (79%) returned to their previous occupation; only seven (10%) retired prematurely on the basis of disc disease alone. Based on Prolo's functional economic outcome rating scale, 60 patients (90%) showed excellent economic outcome. Posterior cervical foraminotomy is an efficient means of decompressing lateral spinal roots compromised by soft disk herniations or osteophytic spurs, without the risk of an anterior approach with or without fusion. Careful patient selection and microsurgical technique are essential in obtaining consistent, excellent results. Additionally, the recent trend toward minimally invasive techniques and key-hole operations in neurosurgery and other specialisations favours the posterior approach.

Malignant prolactinoma: case report and review of the literature.

BACKGROUND: Malignant prolactinomas are rare events. To date, only 14 patients with metastases in- or outside the central nervous system have been reported. CASE DESCRIPTION: We present a patient who developed a metastasis to the cauda equina, which is the first case documented with MRI. A giant prolactinoma in this 51-year-old man was partially removed by a transcranial approach. After radiotherapy and treatment with bromocriptine, the patient had a remission for 3 years. Thereafter, a sacral intraspinal tumor was diagnosed. Because of increasing prolactin levels not responding to bromocriptine and a radiologically suspected intrasellar tumor, we operated transsphenoidally first and found only fibrous tissue. We performed a sacral laminectomy and almost totally removed an intradural tumor. Histopathology and immunohistochemistry confirmed the diagnosis of a prolactinoma metastasis. The patient received radiotherapy and bromocriptine and has no evidence of recurrent tumor or metastases after a follow-up of 38 months, thus being the second reported patient with long-term remission of the disease. DISCUSSION: We review the literature on this topic and try to establish common features of the course of this rare malignant disease and the efficacy of therapy in the cases reported hitherto.

[Why still use myelography in neurosurgery?]. / Warum immer noch Myelographie in der Neurochirurgie?

Recently CT scan and NMR imaging have become diagnostic routine methods for spine lesions, while myelography is no longer the method of choice in most cases. From the experience of our clinic, however, there remain some neurosurgical indications, which will be the contents of this publication. We would like to give a review of the present literature. Still remaining indications are: 1. Traumatic nerve root lesions 2. Anomalies of lumbosacral nerve roots 3. Cervical disc herniation: anterior disc excision vs. posterior operation. 4. Stenosis of the spinal canal in more than 2 levels 5. Neurological deficit after trauma of the spine 6. Functional Myelography 7. Spinal arteriovenous malformations 3 Patients are presented in the crucial phase of diagnostic evaluation. Based on their outcome, the indications of myelography are discussed.

[Supratentorial glioma: analysis of clinical and temporal parameters in 163 cases]. / Supratentorielle Gliome: Analyse klinischer und zeitlicher Parameter in 163 Fällen.

163 cases of supratentorial astrocytomas and glioblastomas were evaluated retrospectively after close-meshed observation and treatment. We attached the greatest importance to the reevaluation of already known prognostic parameters and to the temporal analysis of the course of gliomas. We could confirm the influence of the histologic grade on the survival time. Histologic grading by means of immunohistochemistry proved to be more precise than grading only by means of HE staining. Furthermore, the patient's age was one of the most important prognostic variables for survival time after operation. Other factors were the first preoperative Karnofsky rating, the preoperative diameter of the tumour, the duration of preoperative symptoms and the interval between operation and diagnosis of tumour recurrence as well as between tumour recurrence and reoperation. Epileptic seizures as preoperative symptoms were found to be far less prognostic for survival time. Localisation of the tumour, other preoperative symptoms, Karnofsky rating before reoperation and the extent of tumour resection proved to be of no importance for survival time.

[Whiplash trauma of the cervical spine from the neurosurgical, traumatologic and psychologic viewpoint]. / Das Schleudertrauma der HWS aus neurochirurgischer, traumatologischer und psychologischer Sicht.

Since the early 50's, whiplash injury has been a subject of intensive study in order to find out the genesis of this disease. Unfortunately, most of the studies were planned retrospectively and were based on inhomogeneous groups of patients. In our prospective study, we tried to keep the patient group homogeneous. 62 patients were examined neurologically and radiologically immediately after the accident. Furthermore, they underwent a psychological test, the so-called Freiburg personality profile. 6 months later the patients were checked again. On the basis on our findings, the suspected psychological influence has to be confirmed. Preexisting degenerative lesions of the cervical spine, also, are undoubtedly prognostic for longer-lasting symptoms.

Peri-operative elastase-alpha-1 proteinase inhibitor in patients with postoperative intervertebral discitis.

In a prospective study of 251 patients operated upon for lumbar disc herniation it has been investigated whether the preoperative and early postoperative values of Elastase-alpha-1 Proteinase Inhibitor (EPI)-an indicator of inflammatory processes-and C-reactive Protein (CRP)-a well known predictor of some postoperative complications-were correlated to the later development of discitis. Postoperatively discitis developed in 14 patients. A randomly chosen group of 15 complication-free patients out of the total of 251 cases was used as control group. Elevated EPI plasma values, especially in the pre-operative and first postoperative days, turned out to be significantly related to the likelihood of later discitis development, but no such relation for the CRP plasma values could be established. Thus and early prediction of patients at risk for this complication seems to be possible by pre- and postoperative measurement of EPI. It could be justified-but its usefulness has yet to be proven-to give antibiotics prophylactically and other anti-inflammatory medication in patients with elevated pre- and postoperative EPI values.

Development of supratentorial astrocytomas.

Six cases of supratentorial astrocytomas are presented in this study in order to demonstrate the typical development of this kind of tumors. All patients were controlled regularly by CT scan. Five of them were operated two times, one patient three times. The tumor growth was quite similar in all cases. Time interval between the first intervention and tumor recurrence was larger than between second intervention and tumor recurrence. In all cases the tumors tended to "explosive" growth after the second operation. There are discussed pros and cons of an early reintervention after tumor recurrence.

Somatosensory and auditory brainstem evoked potentials during choroid plexus angioma removal.

Intraoperative combined SEP and BAEP monitoring provides a high level of safety for patients undergoing high risk intracranial surgical procedures. We performed this type of monitoring in a rare case of choroid plexus angioma, embedded into the pulvinar of the right thalamus, which was resected via a transcallosal approach. The SEP pattern deteriorated during parietal brain retraction and thalamic dissection, but never completely disappeared. The BAEP pattern remained unchanged during the entire operation. The patient suffered incomplete hemiparesis postoperatively, but recovered completely within 10 days. After this time the SEP pattern returned to normal. This case points out that pathological change of intraoperative SEP pattern without loss of components suggests an incomplete hemiparesis. There is, however, a good chance of full recovery in the early postoperative period.

Microthrombi formation after severe head trauma.

This study was undertaken to look for trauma-related fibrinous microthrombi in traumatized human brains. Fifty brains from patients with variable time intervals between trauma and death were fixed in 10% formaldehyde. Sections from the contusioned area and from the corresponding area of the contralateral hemisphere were embedded in paraffin and 50 non-traumatized brains were used as controls. After sectioning and embedding, 10 microns sections were stained with haemalum and eosin (HE) and phosphotungstic acid-hematoxylin (PTAH). Stained fibrinous microthrombi were counted in each hemisphere and in control sections. More microthrombi could be found in the contusioned areas of the brain than in the contralateral side or in control sections.

[Percutaneous lumbar thermal sympathectomy: method, indications and results]. / Perkutane lumbale thermale Sympathektomie: Methode, Indikationen und Ergebnisse.

Thermal lumbar sympathectomy has been the method of choice since the 'eighties in the treatment of reflex dystrophy. We are using this method since January 1990. First results are presented and critically analysed. 15 patients who underwent thermal lumbar sympathectomy were examined and interviewed 1 year after treatment. 7 patients reported persisting pain relief, while the remaining 8 did not.

[Spontaneous healing of a carotid-cavernous sinus fistula]. / Spontanheilung einer traumatischen Carotis-Sinus-cavernosus-Fistel.

After a fall, a 67-year-old patient was admitted to our hospital. The unique clinical sign was an exophthalmus, which led to the diagnosis of carotid-cavernous sinus fistula. During his stay in our clinic the fistula was verified by CT and angiography. Transfemoral embolization was planned, but the fistula closed spontaneously prior to the intervention.

Clinical and electrodiagnostic findings, nerve biopsy and blood group markers in a family with hereditary neuropathy with liability to pressure palsies.

Clinical, electrophysiologic and biopsy findings as well as studies of blood group markers in a family with hereditary neuropathy with liability to pressure palsies (HNPP) are reported. There was an autosomal dominant trait without genetic linkage between the HNPP gene and blood group markers controlled by chromosome 1. Reduced motor and sensory nerve conduction velocity was found in clinically affected and unaffected nerves. Characteristic morphological changes in sural nerve biopsy including tomaculous swelling were present.

Free sequestered disc herniation at the S2 level misdiagnosed as neuroma.

The case of a 38 year-old-man with a mass at the S2 level similar to a benign nerve root tumor (neuroma) is reported. The CT scan examination revealed the mass close underneath but not in connection with a disc herniation at the L5/S1 level. During operation the mass was not encountered as tumor but as free sequestered disc herniation, which was confirmed by histological examination. The reasons for considering the mass a tumor are discussed.

The prognostic value of somatosensory evoked potential monitoring and tumor data in supratentorial tumor removal.

The aim of this study was to find appropriate somatosensory evoked potential (SSEP) and tumor data that would predict immediate postoperative outcome. Seventeen patients were evaluated, all with supratentorial mass lesions. Intraoperative SSEP monitoring was carried out, and central conduction time, N20 amplitude, and N20 to N13 amplitude ratio were recorded throughout the operation. The differences between the end and the start of the procedure and between the end of the operation and the most substantial changes during tumor removal were calculated for statistical evaluation. Tumor location and extent were carefully determined and calculated by computed tomographic reconstructions in the axial and sagittal planes. Several tumor parameters were measured: the distances from the midpoint of the tumor to the central sulcus, midline, and base of the skull and the longitudinal and cross-sectional diameters. The electrophysiologic and tumor data sets were correlated with the immediate postoperative neurologic deterioration. For this purpose, patients were divided into two groups: group 1 = no neurologic deterioration after operation (13 patients); group 2 = neurologic deterioration after operation (4 patients). The difference in central conduction times between the end and the start of the procedure was the only variable that exhibited a significant influence on the immediate postoperative condition (P = 0.007), as determined by analysis of variance. The other electrophysiologic data as well as the tumor data failed the significance threshold of P = 0.05. Discriminant analysis was applied to test the classification capacity of the measured variables. Involving all measured variables (electrophysiologic and tumor data), discriminant analysis allowed a correct classification of all 17 patients to their proper neurologic deterioration group. Discriminant analysis for SSEP data alone led to 15 correct classifications. Tumor data, used alone for discriminating procedures, revealed 14 correct classifications. When each variable was analyzed separately, only the difference in central conduction times between the end and the start of the procedure gave significant predictions, namely, 15 correct classifications. This was the same number as achieved by all electrophysiologic variables together. No other variable could on its own yield any valid prognosis for assessment of immediate postoperative neurologic deterioration. The data confirm the importance of central conduction time recovery before the end of the operation on the patient's immediate postoperative neurologic condition.

Changes of somatosensory evoked potentials with increase of intracranial pressure in the rat's brain.

Somatosensory evoked potentials (SEPs) to various combinations of two independent brain compression modalities (localized epidural pressure and intracerebral pressure evoked by an inserted balloon) were investigated in 24 rats. The SEP pattern in response to gradually expanding volume without additional epidural pressure remained unchanged for a certain period. SEP changes occurred only shortly prior to death. On the other hand, remarkable SEP changes were observed in a gradually expanding intracerebral mass, when combined with epidural pressure application at about 50% of the lethal volume. SEP changes in response to intermittent and continuous epidural pressure, in addition to a small intracerebral mass, were investigated too. Intermittent application of minor epidural pressure led to specific P1 changes, which recovered after each pressure step. The same pressure, administered continuously, evoked SEP changes with only partial recovery in some instances. Severe epidural pressure, administered intermittently, gave rise to severe SEP changes with only partial recovery after each step. The same epidural pressure delivered continuously led to SEP changes with very small recovery. SEPs have proved to be a reliable method for signalling brain dysfunction corresponding to various modalities and degrees of intracranial pressure.

[Brain abscess. Prognostic factors]. / Der Hirnabszess. Prognostische Faktoren.

Thirty-eight cases of cerebral abscess were analysed retrospectively for any factors that might influence outcome. Using the "Glasgow outcome score", age, history, level of consciousness, as well as various computed tomography findings (cisternal swelling, compression of the ventricular system, degree of oedema and size of abscess) were considered for their prognostic value. It was found that age over 40 years and clouded consciousness exerted a statistically significant unfavourable effect (P less than 0.05). Outcome was also unfavourable in half the patients with multiple abscesses, but the number of cases (six) was too small to be statistically significant. All other variables had no statistically significant influence on prognosis.