[Pneumocephalus as a rare complication of general anesthesia]. / Pneumozephalus als seltene Komplikation einer Narkose.

This article reports a case of massive postoperative pneumocephalus in a patient following general anesthesia for a urological procedure. The patient had sustained a severe head injury more than 10 years ago with long-term treatment in an intensive care unit (ICU) including decompressive craniectomy, tracheostomy followed by rehabilitation, decanulation and cranioplasty. The patient recovered but suffered severe hemiparesis and mild neurocognitive deficits. Immediately after the current operation the patient was disoriented and did not recover in an appropriate interval. A cranial computed tomography (CT) scan revealed massive intracranial air and frontobasal skull defects. After frontobasal reconstruction, removal of an old lumboperitonal shunt and placement of a ventriculoperitoneal shunt, intracranial air was no longer observed. In summary a frontobasal injury may become symptomatic many years after injury, especially when face mask ventilation with positive pressure is applied during surgical interventions.

Detection of intracranial circulatory arrest in brain death using cranial CT-angiography.

BACKGROUND AND PURPOSE: Computed tomographic-angiography (CT-A) is becoming more accepted in detecting intracranial circulatory arrest in brain death (BD). An international consensus about the use and the parameters of this technique is currently not established. We examined intracranial contrast enhancement in CT-A after clinically confirmed BD, compared the results with electroencephalography (EEG) and Transcranial Doppler Ultrasonography (TCD) findings and developed a commonly applicable CT-A protocol. METHODS: Prospective, monocentric study between April 2008 and October 2011. EEG, TCD and CT-A were performed in 63 patients aged between 18 and 88 years (mean, 55 years) who fulfilled clinical criteria of BD. Evaluation of opacification of cerebral vascular territories in CT-A was performed in arterial as well as in venous scanning series by a neuroradiologist and a neurointensivist/neurosurgeon together. RESULTS: CT-A demonstrated a 95% sensitivity in detecting intracranial circulatory arrest when analysing arterial scanning series. We never observed venous blood return in internal cerebral veins. In three cases, BD confirmation by EEG failed because of artefacts. Confirmation of BD by TCD failed in two cases because of absent temporal window. In three cases, TCD demonstrated residual blood flow. CONCLUSION: CT-A is easily accessible in almost every hospital, offers a high spatio-temporal resolution, is operator independent and inexpensive. The results of CT-A are comparable to other established brain perfusion techniques in BD. An international consensus should be established to ascertain consistent parameters similar to fixed guidelines for other ancillary procedures to determine BD in order to prevent different scanning and evaluation protocols for detecting intracranial circulatory arrest.

[Organ protective intensive care treatment and simulation-based training]. / Organprotektive Intensivtherapie und Simulatortraining.

In Germany the extent of organ donation is still inadequate and not sufficient to address patients on the waiting lists. Nevertheless, intensive care treatment of potential organ donors does not receive adequate attention. However, because of the increasing age and comorbidities of organ donors in recent years, a sufficient intensive care treatment is indispensable for the success of organ transplantations. Sufficient randomized clinical trials are lacking. This article reviews the current literature and describes approaches for improvement. Multicentre studies and education of medical staff of intensive care units, for example in intensive care simulation for organ protection, could potentially be a successful approach. The improvement and establishment of curricular training and education particularly in simulation workshops might be a promising approach to enhance the quantity and quality of organ donations.

Image-guided endonasal transsphenoidal microsurgical treatment of recurrent microadenomas of the pituitary gland.

BACKGROUND: Neuronavigation is a commonly used technology that provides continuous, three-dimensional information for the precise localization of and surgical trajectory to brain lesions. This study was performed to evaluate the role that navigation can play in assisting microsurgical transsphenoidal surgery for precise localization and removal of recurrent pituitary tumours while simultaneously preserving pituitary gland function. METHOD: During a 6-month period -- July 2004 until December 2004 -- 9 patients with recurrent pituitary tumours (5 female and 4-male) were treated with navigation-guided transsphenoidal microsurgical resection. Surgery was performed via a paraseptal or endonasal transsphenoidal approach. The navigation system Vector Vision (Brain Lab, Heimstetten, Germany) allowed precise localization of the tumours (7 hormonal active and 2 inactive microadenomas) in respect to the pituitary gland, the carotid arteries and the cavernous sinus. RESULTS: Postoperative MRI investigations of the 9 patients treated with image-guided transsphenoidal microsurgery, showed total tumour removal in 7 (77 %) patients and subtotal removal in 2 patients (23 %). One patient (11 %) developed a cerebral spinal fluid (CSF) leak and was treated conservatively. One patient (11 %) had preoperative insufficiency of the corticotrope axis which remained unchanged postoperatively. Of the remaining 8 patients who did not have preoperative endocrinological disturbance, only one (12 %) developed postoperative insufficiency of the corticotrope axis. Out of the 7 patients with hormone active tumours, 5 (72 %) patients showed no more postoperative hormonal activity. CONCLUSION: Microneurosurgical transsphenoidal techniques combined with image-guided systems can precisely define the localization and removal of lesions in the sella region with respect to the margins of important anatomical structures in the neighbourhood and the endocrinological functionality of the pituitary gland.

Endoscope-assisted removal of colloid cysts of the third ventricle.

Colloid cysts are benign space-occupying lesions, which arise from the velum interpositum or the choroid plexus of the third ventricle and are able to produce symptomatic obstruction of the foramina of Monro with resultant hydrocephalus. In our department, we have operated on colloid cysts routinely in an endoscope-assisted microsurgical manner via a key-hole approach. During a period of 10 years, 28 microsurgical resections of colloid cysts of the third ventricle were performed. Seven patients demonstrated colloid cysts inside the third ventricle with obstruction of the right foramen Monro, two patients demonstrated cysts with obstruction of the left foramen Monro. Twelve patients suffered from cysts inside the third ventricle with obstruction of both foramina Monro and five patients demonstrated cysts lying into the third ventricle without obstruction of the foramina. In 21 patients no preoperative therapy was performed outside. Three patients had received shunt systems before in other hospitals, two patients received aspiration of the cysts under stereotactic conditions and two patients received external ventricular drains. Total removal of the cyst was achieved in all patients (100%). No patient received a second operation, because none had a recurrent cyst. All cysts were removed with the cyst wall. Overall clinical improvement was achieved in a long-standing period between 6 and 83 months in 27 (96%) patients. In one patient (4%) the psychomotor disturbance was unchanged and no patient deteriorated. From the microsurgical point of view, the combination of keyhole surgery under endoscopic visual control using preexisting anatomical windows offers an effective minimally invasive approach.

Endoscopic and endoscope-assisted neurosurgical treatment of suprasellar arachnoidal cysts (Mickey Mouse cysts).

Suprasellar arachnoid cysts represent less than 10% of all intracranial arachnoid cysts. Some of them may be quiescent throughout life, some may become symptomatic as they become enlarged and some disappear spontaneously. In this study we discuss the surgical strategies for endoscopic and endoscope-assisted treatment of suprasellar (Mickey Mouse) cysts and analyze the clinical results and experience collected over some years in our department upon doing these operations routinely. Between December 1996 and December 2003, 13 patients (7 female and 6 male patients), mean age 29 years, underwent endoscopic or endoscope-assisted procedures for suprasellar cysts at our department. The indication for surgical treatment was based on the neurological and radiological examination. The goal of surgical treatment was to normalize the cerebrospinal fluid flow and to establish a communication, permanently, between the cyst cavity and the intraventricular or/and subarachnoid space. Intraoperatively we observed in all patients no complications. Seven of 13 patients, who had received shunt systems in other hospitals before admission in our clinic, remained shunt-free postoperatively. Overall clinical improvement was achieved for a long period of between 6 and 74 months in 11 patients, one developed a psychomotor disturbance and another one, who had epilepsy before treatment, was unchanged postoperatively. Our data suggest that suprasellar cysts are well treated by endoscopic or endoscope-assisted procedures with good clinical outcome and low surgical morbidity.

[Subarachnoid hemorrhage without aneurysm]. / Die Subarachnoidalblutung ohne Aneurysmanachweis.

The rupture and bleeding of intracranial aneurysms is the most common cause of a spontaneous, non-traumatic subarachnoid hemorrhage (SAH). In up to 20% of these patients, no aneurysm is found, but the prognosis of these patients is known to be better than in those with aneurysms. The retrospective evaluation of the initial CT- and angiographic findings of 773 patients with spontaneous SAH, who underwent (up to three) 4-vessel DSA, brought a percentage of 12.4% with negative angiography. We found the favourable prognosis of these patients with negative angiography not only to be dependent from the distribution of the hemorrhage, with preference to perimesencephalic pattern, but the initial clinical state. 85% of our patients, who presented with perimesencephalic blood pattern and even 80% of those patients with additional intraventricular hemorrhage but the good clinical condition of Hunt-Hess I/II were discharged without neurological deficits. We recommend the obligatory 4-vessel catheter-angiography (DSA) in all patients with spontaneous SAH, independent of the blood pattern on initial CT, and one control in the presence of other than perimesencephalic subarachnoid hemorrhage, CTA might be reserved for additional controls.