Search

Angiomas and aneurysms of the intracranial space which are associated with an increase in pressure show a considerably worse prognosis than such diseases without an intracranial pressure increase do. In the connection, the occurrence of choked disks and haemorrhages in the fundus of the eye, are of particular importance. Paresis of the eye muscle are less important because in view of the neighbourhood relations they may also occur without an intracranial pressure increase ( paralytical type). Choked disks do not occur very frequently and are almost exclusively found in subarachnoid haemorrhages (apoplectic type).

A report is given on 113 tumours of the 4th ventricle in children (up to the age of 18 years) observed among a total of 1028 cerebellar operations. Of these, 87 (= 77%) tumours were exclusively tumours of the 4th ventricle, in 26 cases the tumour also encroached on adjacent structures (cerebellar hemisphere and vermis, pons and Medulla oblongata). Medulloblastomas were predominant (55%), they mainly occurred in school age. Leading clinical symptom of the tumours of the 4th ventricle - especially in child age - is the increase in intracranial pressure which can often be demonstrated radiologically in this age group. Besides there are coordination disturbances and disturbances of the cerebral nerves; relatively frequently one sees a "vermis syndrome". The initial symptoms, which are in most cases non-characteristic (nausea, headache, also ataxia), are more often than not misinterpreted. Surgically treatment aims at a radical removal of the tumour whenever of possible, which is frequently problematic in children, and the restoration of the pathways the cerebrospinal fluid. Microsurgical techniques clearly contributed to a decrease in the mortality rate which, however, still is very high. This stresses the importance of an improvement of early recognition of these tumours.

Among 210 patients operated on because of processes of the ventricles I to III in the years 1953 to 1983 a continuous outpatient after-treatment was carried out in 64 patients. Departing from the histological findings and differentiation according to the results obtained after tumour extirpation or palliative interventions, the subjective complaints, the residual neurological symptoms as well as the possibilities and limits of occupational and social rehabilitation are discussed.

Within a period of 35 years a total of 570 spinal tumours included 77 intramedullary gliomas (44 astrocytomas and 33 ependymomas including those located in the conuscada region). Initial symptoms, neurological findings at the time of the admittance to the clinic as well as results of the operation are presented. The importance of an early diagnosis is pointed out.

From a total of 1,028 infratentorial tumours operated on at the Neurosurgical Hospital of the Section Medicine of the Karl-Marx University Leipzig in the last 30 years, 167 tumours in the region of the 4th ventrical have been selected. Their statistical processing was carried out with respect to specific localisation, average age, kind of tumour, sex, clinical findings, duration of case history, application of instrumental diagnostic procedures and radicality of operation, success and failure. Some fundamental conclussions are drawn. A subdivision in detail will be contained in the following articles based on this material.

The EEG findings in 177 patients with mainly malignant tumours in the region of the ventricles I-III have been evaluated. The changes were dependent upon the size of the tumours and the kind and direction of their infiltration growth into the paraventricular structure. In case of purely intraventricular spreading of the disturbance of the cerebral fluid circulation normal curves were found. In processes of the third ventricle we found to a greater extent theta-delta paroxysms whereas tumours in lateral ventricles rather caused localised disturbances in the sense of focal findings. Tumours with a growth in a basal direction frequently showed sw-patterns or steep waves. General changes only occurred in an advanced stage of the disease as an expression of the intracranial increase of the pressure.

When hypophyseal tumours are present, eye symptoms are the leading signs; they indicate, however, an advanced tumour stage. On the basis of 274 histologically verified hypophyseal adenomas, pre- and postoperative ophthalmological findings were analysed. Disturbances of the visual acuity were found preoperatively in 85.4 per cent, scotomas in 86.1 per cent and an optical nerve atrophy in 67.2 per cent of the patients. After neurosurgical intervention, 41.8 per cent of the examined patients showed an improvement of the visual acuity and 59.2 per cent a regression of the scotomas. Optical nerve atrophy was found in 78.1 per cent which was a higher percentage than before the operation. Disturbances of the visual acuity or scotomas that have persisted for a prolonged period of time show, just as optical nerve atrophy, a more unfavourable prognosis. So it had to be the aim of a neurosurgical treatment to diagnose the pituitary adenoma at an early time in order to improve the chances of a success. Eosinophilic hypophyseal adenomas are more easily recognisable, because of acromegalia being present in almost all cases. Ophthalmologically, they show less scotomas since they reach the dimensions of the chromophobic or mixed type adenomas only rarely. When blindness has developed, the situation is very serious since only in exceptional cases a recovery of sight is possible.

Tumours in the region of the Foramen magnum are rare (34 cases among more than 1000 infratentorial and 400 spinal tumours). The clinical symptoms can be guiding but they sometimes involve differential-diagnostic difficulties. In dependence upon the starting point and the direction of the development, cerebellar signs or transverse paralysis in the cervical region of the medulla are in the fore. In most cases, supplementary examinations are indispensable (X-ray examinations of the skull and the cervical vertebral column, ventriculography and CT). Angiography is of lesser importance. The anatomical relations of the tumour to its environment not only form the clinical picture, but also bring about therapeutical problems. The use of microsurgical methods has improved the prognosis a little, but nevertheless these disease pictures should be considered to be very serious.

The ophthalmological findings obtained in 254 patients with space occupying processes of the lateral and third ventricles are analysed. Visual disturbances (78%), defects of the visual field (69%), findings of the fundus of the eye (67%) and motility restrictions (24%) were identified. Only in eight per cent the findings of the eye-ground no particular findings were observed. As was expected, signs of cerebral compression were frequently found. Postoperative improvements were found in the choked papilla and motility restrictions were seen where as defects of the visual field and a decrease of the visual acuity were in most cases unchanged or had even increased.

Within 30 years, 1028 operations because of cerebellar tumours have been carried out at the Neurosurgical University Hospital in Leipzig. Of these, 167 were related to tumours within the 4th ventricle or encroaching a little outside of it. In the group of the adults (from the 18th year), 54 observations were made. These patients are subdivided according to histology (ependymomas in the first place), according to clinical findings (high values of cerebral pressure symptoms), according to the duration of the case history in dependence upon histology (long duration of angioblastomas and ependymomas), according to the possibilities of radicality (somewhat below the values in child age), the condition at discharge (better than in child age) and the cause of death (absolute predominance of central causes). A comparison is made with the results obtained with the studied patients in child age. Subsequently, the operation tactics of the Leipzig hospital is dealt with and the respective value of microneurosurgery carried out 10 years before is emphasised. A striking improvement for benign tumours can now only be achieved by a considerably improved early diagnosis.