Are preoperative sex-related differences of affective symptoms in primary brain tumor patients associated with postoperative histopathological grading?

Our objective was to explore the impact of the histopathological tumor type on affective symptoms before surgery among male and female patients with supratentorial primary brain tumors. A total of 44 adult patients were included in the study. Depression and anxiety were measured using the Beck Depression Inventory (BDI) and the State-Trait Anxiety Inventory. Additionally, clinical interviews, including the Hamilton Depression Rating Scale (HDRS), were conducted. The general function of patients was measured with the Karnofsky Performance Status scale (KPS). All measures were obtained before surgery and therefore before the final histopathological diagnosis. All self-rating questionnaires but not the HDRS, showed significantly higher scores in female patients. The functional status assessed with the KPS was lower in female patients and correlated to the somatic part of the BDI. We further found a tendency for higher HDRS scores in male patients with a WHO grade 4 tumor stage compared to female patients. This finding was supported by positive correlations between HDRS scores and WHO grade in male and negative correlations between HDRS scores and WHO grade in female patients. In conclusion the preoperative evaluation of affective symptoms with self-rating questionnaires in patients with brain tumors may be invalidated by the patient's functional status. Depression should be explored with clinical interviews in these patients. Sex differences of affective symptoms in this patient group may also be related to the malignancy of the tumor, but further studies are needed to disentangle this relationship.

Access to the crista galli and the foramen caecum in nasal dermal sinus cysts - lessons learned in a single tertiary care centre.

OBJECTIVE: Several surgical techniques have been suggested for the treatment of nasal dermal sinus cysts (NDSC). We have used several different techniques and have developed a minimally invasive approach. The aim of this study is to describe the evolution to this approach and compare the results with those achieved with our experience of more traditional techniques. METHODOLOGY/PRINCIPAL: A retrospective data collection of patients with NDSC presenting to our clinic between 1998 and 2012 was performed. We initially performed external approaches as outlined elsewhere. With an increasing number of young children requiring surgery, the technique was modified to a less invasive form. This new approach starts with mobilisation of the pit via a tiny skin incision. An open rhinoplasty approach is used to follow the fistula on the nasal bone. Once the fistula passes underneath the nasal bone, an endoscopic endonasal approach is used. Following the fistula cranially, the area of the foramen caecum can be identified. RESULTS: Twelve out of 15 patients (80%) were treated surgically. The transfacial, coronal subcranial and minimally invasive approach was used in 3 (25%), 4 (33%) and 5 patients (42%), respectively. Radical resection was achieved in all patients. Cosmetic problems were present in all patients undergoing a transfacial and in half of the patients after the coronal subcranial approach. Patients treated by the minimally invasive technique remained without sequelae. CONCLUSION: The minimally invasive approach enables a perfect exposure of the fistula up to the crista galli and provides less morbidity and better cosmetic results than the transfacial and subcranial approach.

[Intraoperative neurophysiological monitoring improves outcome in neurosurgery]. / Intraoperatives neurophysiologisches Monitoring verbessert das Outcome in der Neurochirurgie.

Intraoperative Neurophysiological Mo-nitoring (IONM) identifies eloquent areas or nerves fibers during neurosurgical interventions and monitors their function. For several interventions IONM has become mandatory in neurosurgery. IONM increases patient safety during surgery as the risk of neurological deficits is reduced. Safer surgery reduces the time needed for the intervention and thereby reduces risk. IONM contributes to complete resection of tumors, which in turn prolongs patients' survival. Complicated surgical interventions associated with an elevated risk of neurological deficits have only become possible due to IONM. IONM comprises a variety of procedures that are selected for a particular intervention. With appropriate selection of the procedures IONM has been shown to improve neurological and functional outcome after neurosurgical interventions.

The transnasal transclival approach for clivus chordoma.

BACKGROUND: We present our experience using a standardized transnasal transclival approach (TTA) for endoscopic removal of chordomas of the clivus. PATIENTS: 13 patients with clival chordoma (CC) underwent tumor resection. Patients were operated by a surgical team consisting of a rhinosurgeon and a neurosurgeon. All patients underwent postoperative proton radiotherapy. Residual tumor was left in situations where radical removal would have entailed an increased risk of neurological deficits. RESULTS: Radical or near total removal of CC was accomplished in 12/13 patients. Intraoperative MRI (IMRI) was used in 4/13 CC patients. A watertight dural seal presented as the main challenge specifically for tumor extensions resulting in large dural defects. CONCLUSION: The TTA provides an elegant alternative to classical approaches to clival lesions especially for midline tumor locations. For large tumors iMRI is of significant help. Dural reconstruction of large defects emerged as the greatest challenge of this technique even for experienced endoscopic surgeons.

Emergency extra-intracranial bypass surgery in the treatment of cerebral aneurysms.

The need of an emergency bypass in hazardous situations during treatment of intracranial aneurysms has rarely been addressed in the literature. We report our 10 year experience with emergency bypass for aneurysm treatment. We retrospectively analyzed the data of patients who underwent emergency bypass surgery for the treatment of an intracranial aneurysm and compared the results with patients treated with bypass as a planned procedure during the same time period. Three groups were formed: group I, emergency bypass during clipping procedure; group II, emergency bypass for therapy refractory vasospasm; group III, planned bypass surgery. Sixteen patients (35%) out of 46 were treated with emergency bypass. In group I (11 patients) mortality was 37% and a good outcome (GOS 4 & 5) was achieved in 36%. In group II (5 patients) mortality was 20% and good outcome was reached in 60%. In group III (30 patients) mortality was 10% and good outcome was achieved in 86.6%. Outcome was worse in patients with additional SAH. An emergency bypass procedure as part of the aneurysm treatment should be considered in risky situations. Accurate timely decision-making is crucial combined with a fast and secure bypass technique. Treatment of refractory vasospasm with emergency bypasses may help to improve outcome in selected patients.

Conservative treatment of lumbar disc disease: patient's quality of life compared to an unexposed cohort.

BACKGROUND: Lumbar disc disease is a very common condition with a substantial socioeconomic impact. Studies have shown the importance of a multilevel assessment of this disease, as its course is influenced by many factors. Most follow-up studies use the degree of physical impairment to measure the outcome of a certain treatment. This remains unsatisfactory, as physical impairment itself seems to be influenced by the social, psychological and personal condition of a patient. We believe that an overall quality of life assessment is required to evaluate success of treatment. The SF-36 questionnaire seemed appropriate, as it provides consistent data of a patient's overall health status. To ensure measurement of disability due to back pain we combined the SF-36 with the NASS (North American Spine Society) questionnaire, an instrument specific for lumbar spine disorders. METHOD: One year after the last outpatient consultation in our neurosurgical clinic, a SF-36 questionnaire was sent to 636 patients with conservatively treated lumbar disc disease. We used the Mann Whitney Test to compare patient's data with a standard group. The demographics of the standard group were matched with the study cohort. FINDINGS: A total of 486 patients (66.5% males and 33.5% females), mean age 49 years (range 21-82 years), returned the questionnaire. The SF-36 data was usable in 76.4% of the patients. Statistical testing reported a significant impact of the disease on all 8 items of the SF-36 questionnaire. The "Role Functioning - Physical (RF)" item was the most, the "Mental Health (MH)" item the less affected. No statistical difference was found between males and females regarding the impact on single items. The NASS scores were also affected suggesting that lumbar back disorder was the influencing factor for the low SF-36 scores. CONCLUSIONS: Besides impairment in the execution of daily physical tasks, patients with lumbar disc disease also showed a significant impact on the "Mental Health (MH)" item. Early SF-36 assessment could identify subjects with high probability of prolonged recovery and development of chronic pain syndromes. In these patients, an early rheumatologic, rehabilitative and psychiatric treatment might be the key to improve their coping abilities and should become an integral part of the treatment strategy.

Intrasellar malignant peripheral nerve sheath tumor (MPNST).

Intracranial malignant peripheral nerve sheath tumors (MPNST) and intrasellar schwannomas are rare tumors. We describe a case of an intrasellar schwannoma with progression to a MPNST, a finding that, although very rare, extends the differential diagnosis of intrasellar lesions.

Cerebral vasospasm: results of a structured multimodal treatment.

Symptomatic cerebral vasospasm (CVS) with delayed ischemic neurologic deficits affects about one third of the patients after aneurysmal subarachnoid hemorrhage (SAH). In spite of the lack of definite evidence of large clinical trials, the devastating outcome of the natural history of symptomatic CVS demands an aggressive CVS treatment in a practically oriented, structured multimodal treatment regimen. With our treatment protocol good functional outcome could be reached in 66% of the patients with symptomatic CVS. This policy requires close and fast multidisciplinary collaboration between neurosurgeons, neuroradiologists, competent in endovascular interventions, and specialists for neurointensive care. We report on our experience with 79 cases with symptomatic CVS and delayed ischemic neurologic deficit (DIND) after aneurysmal SAH. The different treatment options with CVS are reviewed and practical guidelines for a step by step treatment are given.