Cardiac risk in patients with treatment naïve, first-line medically controlled and first-line surgically cured acromegaly in comparison to matched data from the general population.

INTRODUCTION: Coronary risk factors in patients with acromegaly after first-line transsphenoidal surgery (TSS) or first-line somatostatine analogue (SSA) treatment have rarely been examined. Aim of this study was an evaluation of cardiovascular risk factors and left ventricular hypertrophy (LVH) in 3 different patient groups with treatment naïve, active (ACT), first-line medically controlled (MED) and first-line surgically treated (SUR) acromegaly and a calculation of the Framingham Weibull Risk Score (FS). DESIGN: Retrospective comparative matched case-control study. PATIENTS & METHODS: 40 acromegalic patients (cases aged 45-74 years, 23 men) were matched with respect to age and gender to 200 controls from the general population. 13 patients had treatment-naïve acromegaly (ACT), 12 patients were SSA treated (MED) and 15 patients were operated by TSS (SUR). Coronary risk factors were assessed after 12 months of treatment by interviews and direct laboratory measurements. Only patients normalized for IGF-I in MED and SUR group were included. FS and odds ratios (OR) from multiple conditional logistic regression (matched for age and gender, adjusted for BMI) were calculated. RESULTS: Compared to matched controls ACT patients had higher HbA1c levels (6.9±1.4 vs. 5.5±0.7% (p<0.0001)) and an increased prevalence of left ventricular hypertrophy (LVH) (30.8 vs. 3.2% (p=0.007). MED and SUR groups were similar for gender, age, disease duration and IGF-I levels at diagnosis. Compared to matched controls, MED patients had a significantly increased diastolic blood pressure (89±9 vs. 79±11 mmHg (p=0.001), prevalence of LVH (41.7 vs. 1.7% (p<0.0001), prevalence of diabetes mellitus (33.3 vs. 10.0% (p=0.03)), higher HbA1c levels (6.8±1.3 vs. 5.5±0.7% (p=0.0005)) and a higher FS (21.2±9.7 vs. 12.4±7.7% (p=0.002), OR 1.11 [1.02-1.21] (p=0.01)) while in the SUR group only higher prevalences of LVH (40.0 vs. 4.1% (p<0.0001)) and HbA1c levels (6.4±1.2 vs. 5.5±0.8% (p=0.006)) were found compared to controls. CONCLUSION: When comparing treatment naive, medically treated and surgically cured patients with acromegaly to age- and gender-matched subjects from the general population, we have found an increased cardiovascular risk in patients at 12 months after first-line SSA treatment but not in patients after first-line surgery.

Endovascular treatment of intracranial aneurysms in patients 65 years or older: clinical outcomes.

BACKGROUND AND PURPOSE: A controversial discussion concerning treatment of aneurysms in elderly patients exists. The aim of this study was to analyze clinical outcome in patients older than 65 years harboring intracranial aneurysms after endovascular treatment. MATERIALS AND METHODS: A total of 108 patients aged 65 years or older (mean age, 72 years, range, 65-87 years) were selected for endovascular treatment between 1997 and 2005. A total of 85 (78.7%) patients had an acute subarachnoid hemorrhage (SAH). SAH was classified according to Hunt and Hess (HH) grade: I (n = 16), II (n = 11), III (n = 33), IV (n = 19), and V (n = 6). There were 69 aneurysms that were small; 46, medium; 8, large; and 5, giant. Occlusion rate was categorized as complete (100%), subtotal (95% to 99%), and incomplete (<95%) obliteration according to the Raymond scale. RESULTS: Endovascular treatment was technically feasible in 108 of 113 aneurysms. Complete occlusion could be achieved in 80 patients; basal remnant was seen in 26 patients and a dog ear in 2 patients. Procedural complications included thrombotic vessel occlusion (n = 9), aneurysmal rupture (n = 4), and stenosis of the parent vessel (n = 2). The Glasgow Outcome Scale (GOS) for the patients with SAH after 6 months was good recovery (n = 43), moderate disability (n = 12), severe disability (n = 28), persistent vegetative state (n = 5), and death (n = 18). Outcome for the patients with unruptured aneurysms was good recovery in all 23 patients. On follow-up digital subtraction angiography (DSA) in 69 patients, complete aneurysmal occlusion was confirmed in 81% after 6 months. Five patients with recanalization were re-treated with coiling. CONCLUSION: Endovascular treatment of ruptured and unruptured intracranial aneurysms in this subgroup was safe and effective.

Extensive brain swelling with neurological deterioration after intracranial meningioma surgery - venous complication or 'unspecific' increase in tissue permeability.

OBJECTIVE: We retrospectively analyzed a series of patients who deteriorated after resection of an intracranial meningioma due to extensive brain edema (EBE) with regard to etiology of the neurological worsening and outcome. METHODS: Out of a series of 376 consecutive patients who underwent resection of an intracranial meningioma, 13 (3.5%) experienced postoperative deterioration due to EBE which necessitated prolonged artificial ventilation, tracheal reintubation, or decompressive craniectomy. Clinical data, radiological findings, operative records and follow-up data of these patients were retrospectively reviewed. RESULTS: The study revealed two different patient groups: Patients in group A (n=7) demonstrated edema due to typical venous infarction (VI). A decompressive craniotomy was performed in all but one patient in this group; nonetheless, an acceptable neurological outcome (Glasgow Outcome Scale (GOS) 4) was achieved in only two cases. Patients in group B (n=6) deteriorated due to an EBE of unknown etiology. Mean tumor volume in this group was higher when compared to group A (75 ml vs. 30 ml). In addition, 83% of patients in group B displayed extensive preoperative peritumoral edema compared to only 14% in group A. Three patients in group B required decompressive surgery; however, neurological outcome was more favorable in this group as 83% achieved a GOS of 4 or 5. CONCLUSION: Extensive brain swelling during or after intracranial meningioma surgery may be due to VI or possibly due to increased postoperative tissue permeability. It is recommended to preserve all venous structures as patients with VI had an unfavorable neurological outcome.

Predictive value of intrathecal interleukin-6 for ventriculostomy-related Infection.

BACKGROUND AND STUDY AIM: Early diagnosis of ventriculostomy-related infection (VRI) is crucial for the early treatment and course of this disease. In neurosurgical patients the diagnostic criteria are equivocal, mostly because of bloodstained cerebrospinal fluid (CSF). The predictive value, sensitivity and specificity of intrathecal interleukin-6 (IL-6 (CSF)) has been proven for VRI compared with classical diagnostic CSF parameters, i.e. cell countCSF (CC (CSF)) and total protein (CSF). PATIENTS AND METHODS: We prospectively analyzed the daily clinical data and CSF samples of 75 neurosurgical patients with an external ventricular drainage (EVD), which had been inserted predominantly because of poor-grade subarachnoid hemorrhage (SAH). The intrathecal interleukin-6 concentrations (IL-6 (CSF)) were correlated with the clinical course and VRI incidence, as diagnosed by the classical VRI criteria (CC (CSF), total protein (CSF), clinical symptoms). RESULTS: Based on classical criteria, bacterial meningitis occurred in 26.7% of patients. Patients with VRI manifested significantly (p<0.001) higher median values of IL-6 (CSF) (up to 2,000-fold increase) the day before (day -1) infection was diagnosed by conventional parameters. Using a cut-off value of IL-6 (CSF)>or=2,700 pg/ml [4,050 pg/ml after WHO standardization] on day -1, the relative risk for VRI was 6.09 (95% CI: 2.62-14.18%). A predictive value of IL-6 (CSF)>or=2,700 pg/ml [4,050 pg/ml] for VRI was calculated of 89% (95% CI: 79.6-98.0%), a sensitivity of 73.7% and a specificity of 91.4%. The amount of intrathecal blood was an independent risk factor for VRI occurrence, whereas the mean duration of EVD in place showed no impact on the rate of infection. CONCLUSION: Our data indicate that IL-6 (CSF) is a reliable marker for predicting VRI prior to clinically manifest meningitis, one day earlier than the common diagnostic criteria of CSF infection (CC (CSF), total protein (CSF), clinical symptoms).

Intracranial hemangiopericytoma: treatment outcomes in a consecutive series.

OBJECTIVE: The purpose of this study was to analyse a series of patients harbouring an intracranial hemangiopericytoma (HPC) with respect to clinical presentation, treatment results and long-term follow-up outcomes. PATIENTS AND METHODS: Clinical data were retrospectively obtained in a series of 12 patients who underwent microsurgical resection for HPC at two neurosurgical institutions between 1987 and 2004. RESULTS: The main presenting symptoms in the seven men and five women (mean age 38 years) were headache in 50% and epileptic seizures in 33% of the patients. A Simpson grade I resection was achieved in seven patients (58%) and none of these patients developed local tumour recurrence after a mean follow-up period of 127 months (10.6 yrs). Only one of these patients received adjuvant radiotherapy. A recurrence of the HPC was observed in all patients (42%) who underwent subtotal tumour resection at first surgery (Simpson grade II or higher). Recurrences occurred after a mean period of 39 months (3.2 yrs) after primary surgery and were effectively controlled by surgical excision, radiotherapy and gamma knife radiosurgery. Two patients (17%) developed extraneural metastases which were treated by surgical excision, radiotherapy and salvage chemotherapy. Poly-chemotherapy was ineffective with respect to tumour control in this study. CONCLUSIONS: The study emphasises the importance of total resection of HPC, defined as a Simpson grade I removal, at first surgery. Adjuvant radiotherapy is recommended after subtotal tumour resections. A life-long vigilant follow-up of these patients is mandatory.

Lower cervical disc prolapse may cause cervicogenic headache: prospective study in patients undergoing surgery.

In 1983 Sjaastad published for the first time diagnostic criteria for cervicogenic headache. Until now there have been no prospective studies investigating whether cervical disc prolapse can cause cervicogenic headache. Between July 2002 and July 2003 50 patients with cervical disc prolapse proven by computed tomography, myelography or magnetic resonance imaging were recruited and prospectively followed for 3 months. Patients were asked at different time points about headache and neck pain by questionnaires and structured interviews. These data were collected prior to and 7 and 90 days after surgery for the disc prolapse. Fifty patients with lumbar disc prolapse, matched for age and sex, undergoing surgery were recruited as controls. Headache and neck pain was diagnosed according to International Headache Society (IHS) criteria. Twelve of 50 patients with cervical disc prolapse reported new headache and neck pain. Seven patients (58%) fulfilled the 2004 IHS criteria for cervicogenic headache. Two of 50 patients with lumbar disc prolapse had new headaches. Their headaches did not fulfil the criteria for cervicogenic headache. One week after surgery, 8/12 patients with cervical disc prolapse and headache reported to be pain free. One patient was improved and three were unchanged. Three months after cervical prolapse surgery, seven patients were pain free, three improved and two unchanged. This prospective study shows an association of low cervical prolapse with cervicogenic headache: headache and neck pain improves or disappears in 80% of patients after surgery for the cervical disc prolapse. These results indicate that pain afferents from the lower cervical roots can converge on the cervical trigeminal nucleus and the nucleus caudalis.

[Penetrating gunshot injuries to the head and brain. Diagnosis, management and prognosis]. / Penetrierende Schädel-Hirn-Verletzungen durch Schusswaffen. Diagnostik, Behandlungsmanagement und Prognose.

Gunshot injuries to the head and brain are rare in Germany and the rest of western Europe. With the relatively low number of these injuries here, there are no standard methods of diagnosis and management, and there is some controversy over both. Quite a high proportion of such injuries result from suicide attempts and accidents. The main diagnostic procedure available is computed tomography of the head with contrast medium; in certain cases MRI is indicated. The operative management depends on the extent and prognosis of the injury; a ventricular drain is probably indicated in most cases. Debridement of the bullet's path and removal of the projectile are more controversial. Mortality is extremely high after such injuries; if the victim does survive the prognosis is comparable to that following closed cranial injuries.

Olfactory groove meningiomas: functional outcome in a series treated microsurgically.

BACKGROUND: A systematic investigation of long-term follow-up results after microsurgical treatment of patients harbouring an olfactory groove meningioma, particularly with regard to postoperative olfactory and mental function, has rarely been performed. We reassessed a series of patients treated microsurgically for an olfactory groove meningioma in regard to clinical presentation, surgical approaches and long-term functional outcome. METHOD: Clinical, radiological and surgical data in a consecutive series of 56 patients suffering from olfactory groove meningioma were retrospectively reviewed. FINDINGS: Presenting symptoms of the 41 women and 15 men (mean age 51 years) were mental changes in 39.3%, visual impairment in 16.1% and anosmia in 14.3% of the patients. Preoperative neurological examination revealed deficits in olfaction in 71.7%, mental disturbances in 55.4% and reduced vision in 21.4% of the cases. The tumour was resected via a bifrontal craniotomy in 36, a pterional route in 13, a unilateral frontal approach in 4 and via a supraorbital approach in 3 patients. Extent of tumour resection according to Simpson's classification system was grade I in 42.9% and grade II in 57.1% of the cases. After a mean follow-up period of 5.6 years (range 1-13 years) by clinical examination and magnetic resonance imaging (MRI), 86.8% of the patients resumed normal life activity. Olfaction was preserved in 24.4% of patients in whom pre- and postoperative data were available. Mental and visual disturbances improved in 88 and 83.3% of cases, respectively. Five recurrences (8.9%) were observed and had to be reoperated. CONCLUSIONS: Frontal approaches allowed better resection of tumours with gross infiltration of the anterior cranial base, tumours extending into the ethmoids or nasal cavity and in cases with deep olfactory grooves. Preservation of olfaction should be attempted in patients with normal or reduced smelling preoperatively.

Hypopituitarism following severe traumatic brain injury.

Although hypopituitarism is a known complication of traumatic head injury, it may be under-recognized due to its subtle clinical manifestations. To address this issue, we determine the prevalence of neuroendocrine abnormalities in patients rehabilitating from severe traumatic brain injury (Glasgow Coma Scale < or = 8). 76 patients (mean age 39 +/- 14 yr; range 18-65; 53 males and 23 females; BMI 25.8 +/- 4.2 kg/m2; mean +/- SD) with a severe traumatic brain injury, an average of 22 +/- 10 months before this study (median, 20 months), underwent a series of standard endocrine tests, including TSH, free T4, T4, T3, prolactin, testosterone (males), estradiol (females), cortisol, ACTH, GH, and IGF-I. All subjects also underwent GH response to GHRH + arginine. Growth hormone deficiency (GHD) was defined as a GH response < 9 microg/L to GHRH + arginine and was confirmed by ITT (< 3 microg/L). Pituitary deficiency was shown in 24% of the patients (18/76). 8% (n = 6) had GHD (GH-peak range [GHRH + arginine]: 2.8-6.3 microg/L; GH-peak range [ITT]: 1.5-2.2 microg/L; IGF-I range: 62-174 microg/L). 17% (n = 13) had hypogonadism (total testosterone < 9.5 nmol/L and low gonadotropins in 12 males; low estradiol, and low gonadotropins in 1 female). Total testosterone levels did not correlate with BMI or age. 2 males with hypogonadism also showed a mild hyperprolactinemia (33 and 41 ng/ml). 3% (n = 2) patients had partial ACTH-deficiency (cortisol-peak [ITT] 392 and 417 nmol/L) and 3% (n = 2) had TSH-deficiency. In summary, we have found hypopituitarism in one-fourth of patients with predominantly secondary hypogonadism and GHD. These findings strongly suggest that patients who suffer head trauma must routinely include neuroendocrine evaluations.

Endovascular treatment of middle cerebral artery aneurysms with electrolytically detachable coils.

BACKGROUND AND PURPOSE: Middle cerebral artery (MCA) aneurysms often have an unfavorable aneurysm geometry that might limit endovascular therapy. Our purpose was to analyze the feasibility, safety, and efficacy of coil embolization in a consecutive series of MCA aneurysms chosen for endovascular treatment. PATIENTS AND TECHNIQUES: Of 235 MCA aneurysms seen at our institution during the past 5 years, 36 patients harboring 38 MCA aneurysms were primarily selected for coil embolization: 18 patients had an acute subarachnoid hemorrhage (SAH), 16 of which were due to a ruptured MCA aneurysm. SAH was classified according to Hunt and Hess grade: I (5), II (7), III (5), IV (0), and V (1). RESULTS: Complete occlusion could be achieved in 33 of 38 aneurysms. In 5 aneurysms, coil embolization was not performed because of an unfavorable aneurysm geometry with a wide neck or incorporation of adjacent branches (3) or failed because of insecure coil placement (1) or severe vasospasm (1). Procedural complications included coil protrusion into the parent artery (1), and thromboembolic M2 occlusion (5), with recanalization in 4 of 5 cases. Of 8 aneurysms with initial subtotal occlusion, 3 progressed to total occlusion during follow-up. Three aneurysms had to be retreated, and no patient rebled. Glasgow Outcome Scale at 6 months for the patients with SAH (17/18) was good recovery (12), moderate disability (4), severe disability (0), persistent vegetative state (0), and death (1); outcomes for patients with an incidental aneurysm (17/18) were good recovery (16) and moderate disability (1). CONCLUSION: Endovascular coil embolization can be performed safely and effectively in selected MCA aneurysms. Initial subtotal aneurysm occlusion might progress to total occlusion.

Malignant meningioma as a second malignancy after therapy for acute lymphatic leukemia without cranial radiation.

RATIONALE: Meningiomas in the pediatric age group are very rare tumors, comprising about 1-4.2% of all primary pediatric intracranial tumors. CASE REPORT: We present a 17-year-old patient who suffered from an intraventricular malignant meningioma. At the age of 2 years, acute lymphatic leukemia (common ALL [cALL]) was diagnosed and successfully treated with chemotherapy. There was no cranial radiation therapy. In December 2001, 13 years after diagnosis of cALL, he complained of headache, vomiting, and walking difficulties. Magnetic resonance imaging showed an enhancing mass with cystic components in the trigone of the right lateral ventricle. The tumor was removed completely. Histological diagnosis revealed a malignant papillary meningioma. After removal of a recurrent meningioma 16 months later, he received local radiotherapy. CONCLUSION: Pathogenetic mechanisms, treatment options, and prognosis of meningiomas and secondary malignancies of this age group are discussed.

Treatment of wide-necked intracranial aneurysms with a self-expanding stent: mid-term results.

PURPOSE: To evaluate mid-term clinical and angiographic results after using a self-expanding neurovascular stent and coils for the management of broad-based intracranial aneurysms. METHODS: During the period from August 2001 to October 2004 we treated a total of 42 patients with 44 aneurysms using a self-expandable stent. To date we have data on more than 6 months of follow-up in 25 patients with 26 aneurysms. Aneurysm occlusion was divided into the following categories: 100 % (complete), 95-99 % (subtotal), and < 95 % (incomplete). RESULTS: In 15 aneurysms complete occlusion, in 11 aneurysms subtotal occlusion was initially achieved. Control DSA showed progressive thrombosis in seven aneurysms leading to total occlusion in another 4 aneurysms. Three recanalizations were observed in one large and two giant ICA aneurysms. No vessel occlusion occurred. One vessel stenosis of the stented segment was noted, but it was not clinically relevant. One patient experienced a small embolic infarction after stopping antiplatelet medication. No persistent deterioration of the clinical status occurred. CONCLUSION: Combining a stent with coils seems to be an acceptable treatment option for broad-based intracranial aneurysms. As this special subgroup of treated aneurysms includes only those with an unfavourable geometry, the results are extremely promising.

[Stenting plus coiling: dangerous or helpful?]. / Stenting plus Coiling bei akut rupturierten intrakraniellen Aneurysmen.

PURPOSE: The purpose of this study was to evaluate the procedural risk of treating acute ruptured aneurysms with a stent-coil combination. MATERIAL AND METHODS: Between August 2001 and January 2004 we treated nine acute subarachnoid hemorrhage (SAH) patients with a combination of stents and platinum coils. RESULTS: Six aneurysms were 100% eliminated; the residual three aneurysms had a 95% to 99% occlusion. A transient thrombosis in the stent in one patient could be recanalized by intravenous application of ReoPro. In another patient an occlusive vasospasm at the distal end of the stent was successfully treated with intraarterial Nimotop. Neurological complications occurred in none of the patients. CONCLUSION: In broad-based aneurysms which cannot be clipped or in which any neurosurgical treatment presents an unacceptably high risk (posterior circulation and paraophthalmic aneurysms), treatment using a combination of stent and platinum coils might be an option even in the acute phase of an SAH. Platelet aggregation can be treated with Aspirin and Plavix after placement of the first coil, vasospasms with intraarterial Nimotop, and acute stent thrombosis with GP IIa/IIIb-antagonists.

Surgical treatment of intramedullary spinal cord metastases of systemic cancer: functional outcome and prognosis.

OBJECTIVE: Intramedullary spinal cord metastases (ISCM) of systemic cancer are rare. To date, patients with ISCM tend to benefit only to a limited extend from surgery and adjuvant therapy. Subject of this investigation is to assess predictive factors for surgical outcome and survival and to evaluate the value of surgical radicality in the treatment of ISCM. PATIENTS AND METHODS: Between 1990 and 2004, a series of 146 patients with intramedullary tumors underwent surgical treatment in our institution. Among these, 13 patients with intramedullary cancer metastases (7 adenocarcinomas, 3 poorly differentiated carcinomas, 3 sarcomas) were identified. Standard microsurgical removal of the ISCM was performed. Functional outcome was graded according to a standardized scale and factors influencing outcome and survival were statistically analyzed. RESULTS: Median progression-free survival was 13 weeks and median overall survival was 31 weeks. In 5 patients (38) the intramedullary lesion was the initial manifestation of the malignant disease. All poorly differentiated carcinomas and all sarcomas were resected incompletely. Surgical radicality presented a negative predictive factor for functional outcome, increasing radicality leading to functional deterioration. Age, sex, tumor localization, surgical radicality and the presence of neoplastic meningeosis did not affect survival. CONCLUSION: Surgery of ISCM can be performed with an acceptable operative morbidity. Radicality depended on tumor histology. However, radical tumor removal did not affect survival and was correlated with a poor functional outcome. Therefore, complete surgical removal of ISCM should only be intended in patients in whom an unproblematic excision is feasible.

[Epidural haematoma after operative evacuation of an acute subdural haematoma. Discussion of primary treatment illustrated by an unusual case]. / Epiduralhämatom nach Entlastung eines akuten Subduralhämatoms. Diskussion der Primärversorgung anhand eines ungewöhnlichen Falles.

Subdural haematomas as a consequence of severe head injury often constitute the indication for operative evacuation. Despite intensive care management postoperative computed tomography scans are essential. This is illustrated by an unusual case report of a patient suffering from an epidural haematoma after operation of an subdural haematoma. In addition, the importance of the skull X-ray in the emergency setting and intracranial pressure monitoring are discussed.

Endovascularly or surgically treated vertebral artery and posterior inferior cerebellar artery aneurysms: clinical analysis and results.

OBJECTIVE: To describe the clinical results in patients with aneurysms of the vertebral artery and posterior inferior cerebellar artery complex (VA-PICA) treated by endovascular embolization or surgically in cases considered untreatable by endovascular methods. PATIENTS AND METHODS: During a 5-year-period a total of 28 patients with a VA-PICA complex aneurysm out of 600 patients received definitive treatment, 19 patients by endovascular embolization and 9 patients surgically. Mean age was 54 years (range 9-75 years). Clinical data, intraoperative observations and procedural complications were evaluated. The mean follow-up was 9 months. RESULTS: Hunt-Hess (HH) grades were HH 0-II in 10 patients (35.7 %), HH III in 6 patients (21.4 %) and HH IV + V in 12 patients (42.9 %). Aneurysm size ranged from 2 to 40 mm (mean size 5.5 mm). Aneurysm configuration was saccular 18, fusiform 7 and multilobed 3. Complete occlusion was achieved in all cases. Overall 67.9 % (n = 19) showed a favorable outcome (Glasgow Outcome Score IV + V). Overall procedure-related rate for permanent morbidity and mortality was 3.6 % (n = 1) and 3.6 % (n = 1), respectively. Predictive factors of clinical outcome were the initial clinical HH grade and the Fisher grade. CONCLUSION: Endovascular embolization is an effective method for the treatment of VA-PICA aneurysms. Surgical clipping is still an alternative and should be considered for "uncoilable" lesions. Outcomes showed a close correlation to the initial clinical state and were not dependent on the treatment modality.

Functional outcome after surgical treatment of intramedullary spinal cord tumors: experience with 78 patients.

OBJECTIVE: To analyze factors with impact on the functional outcome for patients with surgically treated intramedullary spinal cord tumors (IMSCT) and to point out characteristics of the different histological entities. SETTING: Neurosurgical Department, University of Essen, Germany. METHODS: Between 1990 and 2000, a consecutive series of 78 patients were referred to our institution and underwent surgical treatment. There were 46 (59%) male and 32 (41%) female patients. Mean age was 43.3 years. Functional outcome was analyzed depending on histological features, age, tumor localization and the extension of involved spinal segments. The mean follow-up period was 34.4 months. Operative removal of the IMSCT was performed under standard microsurgical conditions with intraoperative monitoring of somatosensory-evoked potentials (SSEP). RESULTS: The most frequently involved localization was the cervical and cervicothoracic region (55%) followed by the thoracic region (32%) and the medullar conus (13%). The most frequent IMSCTs were neuroepithelial tumors in 44 patients (56.5%) including 32 patients with ependymomas, 15 astrocytomas, and two lesions without further histological classification. Non-neuroepithelial tumors included 10 metastases, nine cavernomas, eight hemangioblastomas, one dermoidal cyst and one enterogenetic cyst. Complete tumor removal was achieved in 65 cases (83.3%) and subtotal resection in nine cases. In four cases a biopsy was performed only. The overall postoperative neurological state was improved or unchanged in 51 patients (65.4%) and worsened in 27 patients (34.6%). A favorable functional outcome was observed in 94.1% of patients with vascular tumors, in 61.3% of patients with low-grade neuroepithelial tumors and in 53.3% of patients with malignant tumors. CONCLUSIONS: The strongest predicting factor of functional outcome was the preoperative neurological condition beyond the histological differentiation of the IMSCT. Although there was no outcome difference with respect to the age and tumor extension, thoracically located IMSCTs proved to harbor an increased risk of postoperative surgical morbidity.

The supraorbital keyhole approach via an eyebrow incision for resection of tumors around the sella and the anterior skull base.

OBJECTIVE: This study evaluates the technique, indications, advantages and limitations of the minimal invasive supraorbital keyhole approach via an eyebrow skin incision for resection of tumors around the sella and the anterior skull base. METHODS AND RESULTS: In 9 patients (5 males, 4 females) different tumors (6 meningiomas, 1 craniopharyngioma, 1 Rathke's cleft cyst and 1 hypophysitis) with a maximum diameter of 30 millimeters were resected via a small eyebrow incision and a supraorbital keyhole craniotomy. Details of the operative procedure include the use of a high-speed drill, a microsaw, bayonet-shaped instruments, careful microsurgical dissection, the use of a neuroendoscope and miniplates for closure. In all patients complete tumor removal was achieved. Mean duration of surgery was 01 h 51 min and mean hospital stay was 8.9 days. There were no significant postoperative complications. Clinical examination and MR imaging after a mean follow-up of 313 days revealed no tumor recurrence and a very satisfying overall functional and cosmetic result in all patients. CONCLUSION: The eyebrow incision supraorbital keyhole approach proved to be safe, effective and time-sparing. The authors recommend this approach for resection of small tumors around the sella and the anterior skull base in selected cases as a valuable alternative to standard skull base approaches.