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Clinical and genetic data of 10 patients with neurofibromatosis 2 (NF-2) are presented. Interestingly, no family history of neurofibromatosis was detectable in any of them, which indicates that these are sporadic cases of NF-2, most likely due to a new mutational event. According to our own results and the data in the literature, sporadic cases of NF-2 are clinically characterized by a high incidence of multiple meningiomas and spinal tumors in addition to the bilateral occurrence of acoustic neurinomas. The clinical heterogeneity of NF-2 is pointed out and the possible existence of different forms of this disease is discussed.

AIM The authors present the therapeutic management of a 12-year-old boy with known hereditary multiple exostosis syndrome (HME), who developed spinal cord compression symptoms caused by an exostosis of the C2 lamina. A perinatal brain lesion with tetraparesis delayed the recognition of the spinal cord compression substantially, which resulted in an extensive spur-like growth of the exostosis. METHOD In comparison with already published cases, this growth pattern was rather unique and required consideration on the best surgical management. We decided to monitor the spinal cord function from positioning of the patient to skin closure and to modify the surgical steps of the laminectomy with initial lateral cutting of both hemilaminae. RESULTS Electrophysiological monitoring helped to avoid spinal cord compression by inadequate head anteflexion during positioning. Lateral cutting of the hemilaminae C2 resulted in spontaneous extrusion of the exostosis with immediate improvement of the electrophysiological findings. The boy experienced a prompt improvement of his neurological deficits. CONCLUSION The good surgical and clinical result confirm the value of the applied management concept.

Bisher ist uber fruhe Pradiktoren der spateren gesundheitsbezogenen Lebensqualitat nach einem Schadel-Hirn-Trauma (SHT) wenig bekannt. Daher wurde in einer Studie die prognostische Bedeutung von klinischen Parametern untersucht, die in den ersten 3 Tagen nach Trauma erhoben worden sind. Dazu wurden konsekutiv die Daten von 111 Patienten durchschnittlich 19,3 Monate nach SHT mittels des Aachener Lebensqualitatsinventars nachuntersucht. Nach der Aachener Komaskala (ACS) hatten 14% ein schweres, 26% ein masiges und 60% ein leichtes SHT erlitten. Die Auswertung zeigte, dass ein SHT zu einer Beeintrachtigung der spateren gesundheitsbezogenen Lebensqualitat fuhrt. Dabei konnte eine substanzielle Assoziation mit dem initialen Bewusstseinszustand (ACS), dem Alter und dem Ausmas der traumatischen Subarachnoidalblutung nachgewiesen werden. Die Ergebnisse belegen, dass klinische Parameter bedeutsame Pradiktoren insbesondere von Beeintrachtigungen des physischen Aspekts der Lebensqualitat nach einem Schadel-Hirn-Trauma sind. Fur die psychosozialen Beeintrachtigungen mussen jedoch andere Pradiktoren gesucht werden.

Health-related quality of life has become an important criterion for assessing disease impact and treatment outcome. Therefore, we developed a questionnaire called Aachen Life Quality Inventory (ALQI) for the use in neurosurgical patients with brain damage. The ALQI is derived from the German version of the Sickness Impact Profile (SIP). The 117 items are formulated on a concrete behavioral level covering the following dimensions of health-related quality of life: 1. activation; 2. mobility; 3. house-work; 4. social contact; 5. family relations; 6. ambulation; 7. work; 8. free-time activities; 9. autonomy; 10. communication; 11. cognitive capacity. As in the SIP, a summary score of total impairment (ALQI Total score), a summary score covering the psycho-social dimension (ALQI Psycho-social score) and a summary score covering aspects of physical functioning (ALQI Physical score) can be calculated. The ALQI consists of a self-rating and a parallel proxy-rating version. The ALQI was validated and psychometrically verified using the data of as yet 231 neurosurgical patients with brain damage of mixed etiology (subarachnoid hemorrhage, closed-head injury, benign brain tumors). Internal consistency (Cronbach's Alpha) ranged from.68 to.91 for the subscales, while it was.97 for the whole instrument,.94 for the psycho-social and.93 for the physical score. The internal consistency for the subscales of the proxy-rating version of the ALQI ranged between.77 and.92, while it was.97 for the whole inventory and.94 for the psycho-social and the physical scores, respectively. Examination of construct validity revealed substantial correlations with a wide range of relevant neurological, neurosurgical and neuropsychological parameters. Beyond other findings, substantial associations emerged with several neuropsychological tests (r =.30 to r =.50), the Glasgow Outcome Scale (r =.39; p

Objective: Endoscopic third ventriculostomy (ETV) is an alternative to shunt placement in occlusive hydrocephalus. The negative impact of anatomic anomalies and variants on ETV have been sporadically reported but not yet investigated systematically. Therefore, the objectives of the present study are 1) to evaluate the frequency of endoscopic anatomic anomalies of the ventricular system, 2) to define their potential to complicate the procedure and to compromise the surgical results, and 3) to investigate the value of preoperative magnetic resonance (MR) imaging for their detection. Method: The video recordings, the operative reports, and the preoperative MR images of 25 hydrocephalic patients who underwent ETV were reviewed. The surgical results were classified into completed and successful, completed, but failed, and unsuccessfully attempted ETV and were correlated with the absence or presence of anatomic variants. Results: In 9 of the 25 patients, 10 anatomic anomalies or variants, respectively, were identified, accounting for an incidence rate of 36%. The single most common anatomic anomaly was a thickened third ventricular floor in 4 patients. Anatomic variants extended the operation time (n=6), increased the stretching of floor and walls of the third ventricle during perforation (n = 4), were related to minor arterial bleeding (n = 3), and obscured the visual control of the basilar artery (n = 2). In 5 of the 9 patients, ETV was completed and successful, but in 2 patients, ETV was finally abandoned, and in an additional 2 patients, ETV was completed, but failed to cure the symptoms of hydrocephalus. In contrast, ETV was completed and successful in all 16 patients with normal anatomy. All anatomic anomalies had been detectable on preoperative MR imaging, with the exception of the thickened floor of the third ventricle. Conclusion: Anatomic anomalies are a frequent finding during ETV. Successful perforation and control of the hydrocephalus correlates with the absence of anatomic anomalies. Most anatomic variants have the potential to increase the operative risk. With the exception of the thickened third ventricular floor, MR imaging allows us to identify all anatomic anomalies preoperatively, and enables the neurosurgeon to weigh the operative risk in a patient with an anatomic anomaly against the chance to perform ETV successfully.

Die aktive und intensive Behandlung eines Patienten mit Schadel-Hirn-Trauma (SHT) erhoht seine Chance auf Erholung deutlich im Vergleich zum Spontanverlauf. Trotz rucklaufiger Morbiditat und Letalitat hat sie aber wegen der Irreversibilitat einmal stattgehabter cerebraler Schaden Grenzen. Im Mittelpunkt steht die Vermeidung primarer und sekundarer Schaden durch die Beherrschung einer intrakraniellen Druckerhohung als Folge von Blutungen, Hirnschwellung und Liquorzirkulationsstorungen. Als Eckpfeiler der Therapie haben sich bei traumatischen Blutungen ihre operative Evakuation, beim Odem die Gabe von Mannitol und eine milde Hyperventilation und beim Liquoruberdruck eine therapeutische Liquordrainage etabliert. Bei therapieresistenten Hirndrucken kann auf Barbiturate und auf kurzzeitige, aggressive Hyperventilation zuruckgegriffen werden.

Congenital plasminogen deficiency is an infrequent disorder, which usually becomes symptomatic as ligneous conjunctivitis. However, pseudomembranous lesions in the mucosa of the pharynx, tracheobronchial tree, and the peritoneum may likewise occur. An accompanying hydrocephalus is extremely rare; only 16 cases have been reported to date. The reports indicate that hydrocephalus, even if treated by ventriculoperitoneal (VP) cerebrospinal fluid (CSF) shunting, worsens the prognosis substantially. Thus, VP CSF shunting does not seem to be the optimal therapy for hydrocephalic children with plasminogen deficiency. We add two cases to the literature, and, on the base of our experience, we propose a management strategy for the hydrocephalus. We report the case history of two children with plasminogen deficiency and associated hydrocephalus. Both children initially were treated with VP shunts and had a very similar clinical course with multiple shunt malfunctions due to nonabsorption by the peritoneum. In the first child, the attempt to treat the hydrocephalus with a ventriculoatrial (VA) shunt failed due to catheter thrombosis. Finally, a ventriculocholecystic shunt was placed in both children, which worked well. In patients with plasminogem deficiency and associated hydrocephalus, special care must be taken in the management of hydrocephalus. The absorptive capacity of the peritoneum is reduced by pseudomembrane formation, which results in VP shunt malfunction. The plasminogen deficiency results in early thrombus formation if atrial catheters are used. Therefore, the authors believe that ventriculocholecystic shunting should be considered early on in the course of the disease.

Insertion of ventriculoperitoneal and ventriculoatrial shunts is routinely performed. Infarction pneumonia and atrial thrombus formation are described as very rare complications of ventriculoatrial shunts. We present the case of a female patient with ventriculoatrial shunt insertion as long term treatment for aequeductal stenosis who presented with recurrent episodes of dyspnoea, chest pain, and unilateral pleural effusion. Diagnostic evaluation revealed a positive D-dimer test, bilateral basal infiltrates and pleural effusion. Transesophageal echocardiography established the diagnosis of a thrombus in the right atrium. Laboratory testing for thrombophilia revealed a homozygous factor V Leiden mutation. In the following, a shunt revision was performed.

The authors present the therapeutic management of a 12-year-old boy with known hereditary multiple exostosis syndrome (HME), who developed spinal cord compression symptoms caused by an exostosis of the C2 lamina. A perinatal brain lesion with tetraparesis delayed the recognition of the spinal cord compression substantially, which resulted in an extensive spur-like growth of the exostosis.In comparison with already published cases, this growth pattern was rather unique and required consideration on the best surgical management. We decided to monitor the spinal cord function from positioning of the patient to skin closure and to modify the surgical steps of the laminectomy with initial lateral cutting of both hemilaminae.Electrophysiological monitoring helped to avoid spinal cord compression by inadequate head anteflexion during positioning. Lateral cutting of the hemilaminae C2 resulted in spontaneous extrusion of the exostosis with immediate improvement of the electrophysiological findings. The boy experienced a prompt improvement of his neurological deficits.The good surgical and clinical result confirm the value of the applied management concept.

Schadel-Hirn-Traumen (SHT) stehen als Todesursache in der Altersgruppe bis zu 45 Lebensjahren an erster Stelle [35, 45, 83]. Manner sind 3-mal haufiger von einem SHT betroffen als Frauen. In den Vereinigten Staaten von Amerika bilden SHT mit einem Anteil von 40% die haufigste Ursache von Todesfallen infolge von akuten Verletzungen. Pro Jahr werden ca. 200 000 Patienten stationar in den USA wegen eines schweren SHT behandelt und viele der Uberlebenden bleiben permanent behindert [54]. Zusatzlich sind ca. 1,74 Mio. Amerikaner von einem leichten SHT betroffen, das zumindest die einmalige Konsultation eines Arztes erforderlich macht [83]. In Deutschland erleiden jahrlich ca. 650 000 Menschen ein SHT, das bei ca. 150000 Patienten eine stationare Behandlung erfordert, von denen wiederum ca. 30000 versterben [22]. Alter, Geschlecht und soziookonomischer Status beeinflussen die Inzidenz des SHT in der Allgemeinbevolkerung. So findet sich eine hohere Inzidenz in der Altersklasse zwischen 15 und 24 Jahren, bei Personen mannlichen Geschlechts oder bei Menschen mit einem niedrigen soziookonomischen Status [45, 76]. Die haufigsten Ursachen von Schadel-Hirn-Verletzungen sind Verkehrsunfalle, Sturze und korperliche Gewalteinwirkungen [45, 76, 83]. Die Tatsache, dass die meisten Opfer eines SHT mit einem Alter von 15-24 Jahren [76] sehr jung sind und zu Beginn ihres produktiven Lebens stehen, verdeutlicht besonders die dahinter stehende psychosoziale und okonomische Problematik. Zwar sinkt durch Verbesserungen im akutmedizinischen Management seit einiger Zeit die Mortalitat nach einem SHT [22, 54], doch steigt auf der anderen Seite hierdurch der Anteil an permanent behinderten Uberlebenden. Vor diesem Hintergrund forderte bereits 1989 Ridley einen Paradigmenwechsel weg von der grundlagenwissenschaftlichen Analyse der kognitiven Beeintrachtigungen in dieser Patientengruppe hin zu der Untersuchung der psychosozialen Folgen und ihrer psychologischen Verarbeitung [66]. Jacobson vertrat die noch weitergehende Ansicht, dass die subjektiven Beschwerden nach einem SHT nicht allein durch ein organisches Modell erklart werden konnen, sondern dass neben kognitiv-behavioralen Faktoren auch die Krankheitsverarbeitung berucksichtigt werden muss [36].

A 17-year-old patient with a symptomatic cavernoma of the optic radiation underwent surgery supported by functional magnetic resonance imaging (fMRI), diffusion weighted magnetic resonance imaging (DWI) and navigated 3D-ultrasound. The primary visual cortex was visualized with fMRI. The optic radiation was delineated by means of DWI. The diffusion weigthed images were used for 3-dimensional reconstruction of the optic radiation. During surgery, the information of the localisation of functional brain regions were used together with the 3D-ultrasound, enabling the surgeon to remove the cavernoma without morbidity. This is the first report of the combined use of fMRI, fiber tract imaging and 3D-ultrasound for the safe resection of an optic radiation lesion.

To investigate if the intracisternal distribution of subarachnoid hemorrhage (SAH) following aneurysm rupture allows the correct prediction of the symptomatic aneurysm site. [nl]Ninety-nine consecutive patients with acute SAH and angiographically proven aneurysm were included into the study. The parent vessel of the diagnosed aneurysms were the anterior communicating artery (ACoA) in 38 patients, the middle cerebral artery (MCA) in 26 patients, the internal carotid artery (ICA) in 25 patients, the pericallosal artery (A2) in 5 patients, the basilar artery (BA) in 4 patients and the vertebral artery (VA) in 1 patient. In 21 patients, an additional asymptomatic aneurysm was diagnosed. The initial computerized tomography (CT) scans of the 99 patients were given to 2 experienced vascular neurosurgeons, who were blinded for the angiography findings. The 2 investigators had to predict the site of the ruptured aneurysm. [nl]Investigator 1 correctly predicted the aneurysm site in 56 (57 %), investigator 2 in 59 of the 99 patients (60 %). Investigator 1 correctly identified 81 % of the MCA aneurysms, and investigator 2 74 % of the ACoA aneurysms. However, in only 46 of the 99 patients (47 %), the aneurysm site was correctly predicted by both investigators together. [nl]The results indicate, that the distribution of the subarachnoid blood as shown on the first CT scan after aneurysm rupture barely allows to predict the symptomatic aneurysm site. Thus, neurosurgical decision making (identification of the ruptured aneurysm in patients with multiple aneurysms; surgical exploration in patients with non-perimesencephal SAH, but negative angiography) should not rely on the first CT scan after SAH.

In neonates and infants less than 1 year of age who are treated with a ventriculo-peritoneal shunt, non-infectious complications are almost as frequent and dangerous as infectious complications. While the incidence of infections can be reduced, using perioperative antibiotics, special surgical techniques and postoperative care non-infectious complications such as wound break-down, cerebrospinal fluid (CSF) fistula and subcutaneous CSF collection are preventable, but seem difficult to manage, especially in the group of patients at a susceptible age. The authors present their experience with the programmable Hakim valve in 40 neonates and infants less than 1 year of age, who were treated with de novo implantation of a ventriculo-peritoneal shunt due to various pathologies. The uneventful wound healing during the first weeks after shunt implantation, avoiding the above mentioned non-infectious complications, was supported by initial, temporary overdrainage and readjustment of the programmable valve after completed wound healing. All patients tolerated this procedure well and showed no pathological signs or symptoms of overdrainage like premature closure of cranial sutures, clinical low-pressure syndrome, slit ventricle syndrome (SVS), subdural fluid collection or brain collapse during an average follow-up period of 2.6 years (2 - 65 months). Infectious and other mechanical, non-infectious complications were analysed as well during the follow-up period. These results suggest that an initial, temporary overdrainage in infants and neonates with shunted hydrocephalus may contribute to further lower the incidence of non-infectious complications like wound break-down, CSF-fistula or subcutaneous CSF accumulation, without negative side effects. This technique could be a valuable option in the regimen of shunt-treatment of this age group in order to optimise the overall success rate and lower the general complication rate.

The authors report 118 consecutive cases of patients with traumatic extradural hematoma (EDH) which were analyzed according to different clinical parameters and treatment modalities. Patients, treated for EDH between 1992 and 1998 in our department were distributed into 5 treatment groups depending on their clinical and neuroradiological findings on admission and during the hospitalization. Group I consisted of 75 patients (64%) who required immediate surgical evacuation of the hematoma after admission. Group II included 12 patients (10%) with initially conservative treatment despite visible EDH on the first CT-scan, which had to be operated on in the course because of neurological deterioration or increase of hematoma size. The 14 patients (12%) forming group III developed an acute EDH after the initial CT-scan revealed no extradural blood; 7 patients (6%) out of group IV showed a chronic EDH (delay trauma/diagnosis72 h), which required operative evacuation. All 10 patients (8%) comprising group V were treated conservatively. In each group the following parameters were analyzed: patient age, size and location of hematoma, trauma mechanism, additional intracranial lesions or skull fractures, intraoperative findings and neurostatus on admittance and during the hospitalization. The decision for non-operative treatment of EDH and the timing of a delayed intervention has to be made individually in each case in dependence of parameters like patient age, hematoma-size and -location and neurological status and course. Chronic EDH should be operated immediately, as well as hematomas presenting with an increase in size. Delayed developing EDH imply worse outcome and make adequate surveillance of high-risk patients mandatory.

The authors evaluated the impact of motion artefacts on presurgical mapping of the sensorimotor cortex with functional magnetic resonance imaging (fMRI). Different mapping paradigms were compared with regard to the frequency of motion artefacts and the resulting signal increase.94 surgical candidates with mass lesions near the central region were investigated using BOLD(1)-contrast T2(*) weighted multislice multi-echo EPI gradient echo sequences on a 1,5 T Philips Gyroscan. Three functional paradigms were performed: a) repetitive self-paced clenching of the hand to a fist (68 runs); b) repetitive finger-to-thumb opposition (46 runs); c) sensory stimulation by repetitive brushing of the palm (15 runs). Task-related haemodynamic changes were identified by statistical analysis with the Kolmogorov-Smirnov-test. MR signal increase in percent was calculated for each of the paradigms. Motion artefacts were rated on a scale from 1 to 3.Severe motion artefacts occurred in 8 hand clenching runs and in 2 finger opposition runs. Artefacts were more pronounced in hand clenching than in finger opposition. There were no motion artefacts in any of the sensory stimulation runs. Concerning the percent MR signal change there was no significant difference between hand clenching and finger opposition (T-test: p0,5) but a highly significant difference (p0,0001) between both motor tasks and the sensory paradigm (hand clenching: 2.68+/-0.75; finger opposition: 2.76+/-0.79; sensory stimulation: 1.72+/-0.65).Sensory stimulation causes by far less artefacts than motor paradigms but it also has to be considered less sensitive as it produces a smaller MR signal increase. Therefore in presurgical evaluation sensory stimulation should be kept in reserve for cases in whom motion artefacts are very likely to occur, i.e. patients with severe forms of paresis.

Compressive optic neuropathy (CON) with visual loss is, apart from corneal exposure and disfigurating proptosis, the most serious clinical sign encountered in Graves' ophthalmopathy. However, numerous different approaches and operative techniques have been proposed for orbital decompression, with varying results and side effects. The purpose of the present study was to analyze peri-operative data and long-term results in patients with severe thyroid-related orbitopathy, treated by extended pterional orbital decompression, comparing its effectiveness to other procedures.An extended pterional orbital decompression was performed in 42 consecutive patients (59 orbits) with severe thyroid-associated ophthalmopathy after failure of medical and radiation therapy during an 11-year period. Pre- and postoperative examination included visual acuity, Hertel exophthalmometry, ocular motility, visual fields (Goldmann perimetry) and notification of complications. Long-term evaluation was carried out on average at 11 months postoperatively (range 5-26 months).Visual acuity improved rapidly from a preoperative average of 0.53 +/- 0.33 (range, 0-1) to 0.77 +/- 0.31 (range, 0-1) postoperatively (p0.001). Worsening was not seen. An average reduction of proptosis of 3.79 +/- 2.32 mm (range, 0.5-8 mm) was achieved with a mean preoperative Hertel measurement of 24.7 +/- 3.93 mm (range, 15-33 mm) (p0.001). Double vision and restriction of eye motility was present in 76.3% of patients preoperatively and improved in 63% of patients (p0.001). No new onsets of not already pre-existing double vision was seen. Complications included two cases of permanent palsy of the frontal branch of the facial nerve.The extended pterional orbital decompression improved vision and decreased proptosis and restriction of extra-ocular movements in patients with severe sight-threatening and disfiguring cases of Graves' orbitopathy and is still an effective and low-risk alternative to other non-neurosurgical operative techniques. Especially new developing postdecompression strabismus can be successfully avoided.

Health-related quality of life has become an important criterion for assessing disease impact and treatment outcome. Therefore, we developed a questionnaire called Aachen Life Quality Inventory (ALQI) for the use in neurosurgical patients with brain damage. The ALQI is derived from the German version of the Sickness Impact Profile (SIP). The 117 items are formulated on a concrete behavioral level covering the following dimensions of health-related quality of life: 1. activation; 2. mobility; 3. house-work; 4. social contact; 5. family relations; 6. ambulation; 7. work; 8. free-time activities; 9. autonomy; 10. communication; 11. cognitive capacity. As in the SIP, a summary score of total impairment (ALQI Total score), a summary score covering the psycho-social dimension (ALQI Psycho-social score) and a summary score covering aspects of physical functioning (ALQI Physical score) can be calculated. The ALQI consists of a self-rating and a parallel proxy-rating version. The ALQI was validated and psychometrically verified using the data of as yet 231 neurosurgical patients with brain damage of mixed etiology (subarachnoid hemorrhage, closed-head injury, benign brain tumors). Internal consistency (Cronbach's Alpha) ranged from.68 to.91 for the subscales, while it was.97 for the whole instrument,.94 for the psycho-social and.93 for the physical score. The internal consistency for the subscales of the proxy-rating version of the ALQI ranged between.77 and.92, while it was.97 for the whole inventory and.94 for the psycho-social and the physical scores, respectively. Examination of construct validity revealed substantial correlations with a wide range of relevant neurological, neurosurgical and neuropsychological parameters. Beyond other findings, substantial associations emerged with several neuropsychological tests (r =.30 to r =.50), the Glasgow Outcome Scale (r =.39; p.00) and in patients after subarachnoid hemorrhage with the HuntHess grading (r =.28; p.001). According to these results, the ALQI promises to become a valid and reliable means for assessing quality of life in patients with brain damage. Nevertheless, further analyses using larger patient samples and with particular emphasis on the investigation of the retest-reliability and the prognostic validity are called for in the future.

Background and purpose The authors investigated the feasibility and accuracy of intravascular Doppler sonography (IVDS) with a newly developed microprobe. Methods The known method to determine blood flow velocity by transcutaneous Doppler sonography was transferred to an intravascular usable Doppler probe. With the improved technique, a microprobe measuring 0.3 mm in diameter can be advanced through a 5F catheter used in routine diagnostic angiography to perform intravascular Doppler sonography. In a first step, the conditions for application and measurement were studied in a flow tube model and were transferred in a second step to patients undergoing routine angiography and patients with arterial stenoses. Results Measurements with nondegassed liquids showed a high intensive acoustic signal, but no echo effect could be recorded in degassed liquids. IVDS of healthy vessels in 40 patients showed the same typical flow pulse curve as seen in transcutaneous measurements. The optimal position of the microprobe with respect to the contact of the vessel wall, the diastolic and systolic phase, and the distance to the tip of the catheter could be evaluated. In 95.6% of the 40 patients with healthy vessels, IVDS was successful. Fourteen patients with arterial stenotic diseases were investigated before and after percutaneous transluminal angioplasty, and the results of these investigations correlated well with the angiographical results. Conclusions For percutaneously directly reachable vessels, the transcutaneous Doppler sonography is the choice for easy noninvasive and inexpensive measurement of blood flow velocity. However, for vessels that are difficult or impossible to reach percutaneously, intravascular measurement is a valid procedure.

To analyze the influence of head positioning during preoperative image data acquisition on intraoperative accuracy of modern neuronavigation systems.All measurements were performed preoperatively before opening the head. In 24 patients, preoperative MR image data acquisition was performed twice on a 0.5 T scanner using a contrast-enhanced T1-weighted sequence; first in the neutral head position, and thereafter in the surgical head position for pterional craniotomy. For both data sets, the Sylvian fissure, the central sulcus, and the superior and inferior temporal sulci were depicted on the patient's scalp using the frameless neuronavigation system EasyGuide Neurotrade mark. At the beginning of surgery, with the head fixed in a Mayfield clamp and an articulated instrument holder being used for fixation of the navigation system's pointer, the distances of 10 correlating points of the sulci for the two data sets were measured. To evaluate the accuracy of the navigation system in this experimental set-up, a phantom study was also performed.The phantom study revealed a mean inaccuracy of 1.6 mm (range 0.1-2.3 mm, standard deviation 0.6 mm). The patient study revealed a mean inaccuracy of 1.8 mm (range 0.4-2.8 mm, standard deviation 0.5 mm).The data suggest that the positioning of the patient's head during preoperative imaging plays no relevant role in intraoperative accuracy of neuronavigation. However, further studies and a larger number of patients with various pathologies in different regions of the brain are necessary to obtain a better understanding of the problem of brain shift in neuronavigation due to patient positioning alone, and to avoid procedure-related operative morbidity.

Based on the results of earlier studies it is agreed that the significance of aneurysm location and surgery for neuropsychological impairments after subarachnoid hemorrhage (SAH) is secondary to the effects of the bleeding itself. Therefore, the present study was performed to evaluate whether bleeding, acute clinical course, and surgery have persistent effects on health-related quality of life (QOL) after SAH.A series of 116 patients was examined for 4 to 5 years (mean 52.2 months) after aneurysmal SAH by means of a QOL questionnaire. Eighty-six patients (74.1%) had undergone surgery early (or = 72 hours post-SAH). There were 77 women (66.4%) and 39 men (33.6%) in the study group, and the mean age of the patients was 50.3+/-13.3 years (range 30-69 years). Patients who had undergone surgery for a left-sided middle cerebral artery (MCA) aneurysm complained of significantly more impairments in social contact, communication, and cognition than those treated for a right-sided MCA aneurysm. No other effects of aneurysm location (including the anterior communicating artery) emerged. Multiple aneurysms, intraoperative aneurysm rupture, and partial resection of the gyrus rectus had no adverse effects on later daily life. Only temporary clipping was associated with increased complaints in some QOL areas. Disturbances of the circulation of cerebrospinal fluid and the presence of intraventricular hemorrhage led to more impairments in daily life. Specific effects of the anatomical pattern of the bleeding could be identified, but no adverse effects of vasospasm were found. Multivariate analyses revealed, in particular, that patient age and admission neurological status (Hunt and Hess grade) are substantial predictors of the psychosocial sequelae of SAH.In contrast to the mild effects of aneurysm surgery, patient's age, initial neurological state on admission, and the bleeding pattern substantially influence late QOL after SAH.

Chordomas that are entirely extraosseous and intradural are rare. Additionally subarachnoid spinal implantation from such a cranial, intradural chordoma has never been reported before. The authors present a case of a widespread primary intradural chordoma in the basal cisterns of a 48-year-old woman which shows seeding of neoplastic cells to the spinal leptomeninges. It is concluded that also in cases of intradural and intracranial chordomas a tumor staging should include the search for spinal subarachnoid metastases.

The introduction of the operating microscope, the principle of early surgery, specialized intensive care units, the calcium antagonist nimodipine, the sophisticated pre- and postoperative management and an aggressive antiischemic pharmacological management have substantially reduced morbidity and mortality after aneurysmal subarachnoid hemorrhage (SAH). In spite of this progress, many patients after rupture and surgical repair of an intracranial aneurysm exhibit substantial cognitive deficits and emotional problems although their neurological outcome was rated as good according to the Glasgow Outcome Scale (GOS = I). Therefore, a comprehensive neuropsychological examination is called for in order to evaluate the factual functional outcome after SAH. Neither focal brain damage associated with aneurysm location nor surgery but the hemorrhage itself and related events can be regarded as the most important causal factors for the late result after SAH. In contrast to the mild permanent effects of aneurysm surgery, the initial bleeding itself seems to have substantial lasting adverse neurobehavioral effects after. In concordance with other authors our own data stress the strong predictive power of the bleeding pattern such as the presence of intraventricular and/or intracerebral blood on the functional outcome after aneurysmal SAH.

Surgery of lesions within the central region requires exact intraoperative anatomical orientation and knowledge of the position of functional cortical regions to minimize the surgical trauma and to avoid postoperative neurological deficits. We combined somatosensory evoked potential (SSEP) phase reversal and/or cortical electrical stimulation with neuronavigation in 26 patients for localization and visualization of functional cortical areas and their anatomical site in relation to the lesion. After location of the central sulcus by means of SSEP phase reversal, the precentral gyrus was electrically stimulated to detect functional motor regions. Electrode position was documented, and the functional regions were related to the site of the lesion using a specially developed neuronavigation system. In 11 of 15 patients the central fissure was located with SSEP phase reversal. Electrical stimulation yielded motor evoked potentials in 23 of the total 26 patients. The anatomical site of these functional regions and their relation to the lesion were evaluated with the neuronavigation system. The precentral gyrus, central sulcus, and postcentral gyrus could be identified in all 23 cases. The combination of intraoperative electrophysiological mapping and neuronavigation provides safe and reliable localization of the sensorimotor cortex. This technique is a promising tool to minimize the risk of surgically caused sensory and motor deficits.

This report summarizes our clinical experiences with the neuronavigation system EasyGuide Neuro in a series of 62 cranial neurosurgical procedures. The purpose of this study was to evaluate the accuracy, safety and the routine handling of this system in a wide range of cerebral operations performed from December 1995 to November 1996 in our department.

The transcallosal route has been propagated as a safe approach to midline tumors. The present study was performed in order to elucidate the neurobehavioral late sequelae in patients after transcallosal microsurgery on near-midline tumors.The present study was performed retrospectively with a delay between surgery and follow-up examination ranging from 2 to 36 months (mean 10.2 months).The study was performed in the Department of Neurosurgery, University Hospital of the University of Technology (RWTH) Aachen, Germany.A consecutive series of 18 patients treated for an intracranial lesion by transcallosal surgery was included into the study. The patients had to be not younger than 16 and not older than 67 years. The age mean was 38.9 years (range 16 to 65 years).The surgical approach was performed along the falx cerebi under microneurosurgical conditions with direct use of the microscope after opening the dura.Beyond neurological examinations, the patients were submitted to an extensive neuropsychological testing battery. Furthermore, quality of life was examined by means of a questionnaire.Surgery was performed without persistent new neurological deficits. Cognitive deficits were found in short- and long-term memory, motor fine-coordination, reaction time, divided attention and fronto-cortical capacity. The quality of life was particularly impaired in the area of cognitive capacity in daily life. These findings could be related to the duration of preoperative symptoms and to the tumor location.The deficits found cannot be explained by surgical damage to the corpus callosum itself. Rather, they seem to correspond to an extra-callosal pathology. Further studies with a prospective evaluation of larger patient samples are called for in the future.

The treatment of cerebral aneurysms aims at the complete elimination of the aneurysm from the circulation. In the case of subarachnoid hemorrhage (SAH), early management prevents rebleeding and in incidental aneurysms, future rupture is to be prevented. Standardization of surgical techniques and optimized collateral measures have reduced the morbidity and mortality of early operations in SAH to 10% and 15%, respectively, in most series. As an alternative, endovascular techniques are being developed which attempt to obliterate the aneurysmal sack by packing it with detachable platinum-coils. A major difference between clipping and coiling is the closure of the aperture by the surgical clip which approximates the vessel walls. During coil embolization, that aperture stays open, allowing in some cases further compaction of the coils in subsequent months and years. Recanalization attributable to compaction depends on the size of the aneurysm and may necessitate repacking in up to 40% of the cases (aneurysms25 mm). As for the risk of rebleeding, a recanalized aneurysm is comparable to a partially clipped aneurysm. As the surgical results from early and delayed operations were obtained in randomized controlled studies, such randomized comparative studies will need to be applied to assess the value and risks and long-term results of endovascular strategies.

A neurosurgeon has not received any special training in personnel recruitment at the time he becomes chief of a department. Consequently, a suboptimal personnel policy is most probable. Due to the rapid changes in social behaviour and style of leadership in postwar Europe, he might be ill advised to follow only the example of his successful predecessors, apart from the fact, that this would only be possible if the personalities (of the former and new chief) were similar. To save time and energy for optimal patient care, personnel recruitment can be improved and made more reproducible and reliable by adopting modern, professional non-medical principles. A typical stepwise process of personnel recruitment includes an analysis of the position and function, the definition of demands and offers, the choice of advertising and searching methods, the analysis of the application documents, the interview with the candidate including its re-evaluation and the ongoing evaluation process during the training. This election process is not only conducted by the chief of a department, but also by senior staff-members and even young, competing assistants. It aims to find the candidate who fits best in the requirements, who will be trained and educated with the least effort and who has the best potential to succeed in the long run. The only factors seemingly predicting a good development of a candidate are personality, energy (potential, motivation) and intelligence. Therefore, the search should especially aim to discover these-admittedly difficult to detect-qualities.

This report details a traumatic spinal column lesion due to a lap seat belt. A healthy 22-year-old woman was involved in a car accident and suffered a lumbar luxation fracture at the level L1-L2. She developed acute transsectional symptoms with paraplegia and severe hyperpathia in her legs. Plain radiographs (antero-posterior and lateral projection) and lumbar CT scans demonstrated an instable flexion-distraction fracture with ventral compression of the vertebral body of L2 and ventrolisthesis of L1 over L2. Surgical reposition of the luxation fracture and removal of a spinal epidural hematoma was performed 4 h after the trauma. Stabilization was achieved by monosegmental dorsal transpedicular spondylodesis with a fixateur interne. In follow-up the neurological deficits markedly improved. Six months after the trauma, the patient is able to walk, has no paresis and no genitourinary disturbances: only mild dysesthesia remains. This posttraumatic course confirms that spinal traumas below L1 which spare the conus have a favorable prognosis, because the peripheral nerves of the cauda equina are able to recover. This injured patient was the only one using a lap seat belt; the other four passengers in the same compact car-wearing lap and diagonal seat belts-suffered no harm. We conclude that lap seat belts are not acceptable as an adequate security standard in modern automobile technology.

Aggressive treatment of patients with severe head injury increases the chance for survival and good functional outcome in most cases. To prevent irreversible cerebral lesions, the key point of treatment is the management of intracranial hypertension caused by intracranial hematomas, brain edema and impaired circulation of cerebrospinal fluid (CSF). Therapeutic standards are surgery of traumatic hematoma, osmotherapy and mild hyperventilation for brain edema, and CSF drainage. In highly elevated intracranial pressure (ICP) administration of barbiturates and forced hyperventilation can be considered.

The glucose metabolism of 62 meningiomas was measured by fluorine -18-2-fluorodeoxyglucose (FDG) PET and correlated with proliferation rate (Ki-67 index) and tumor cellularity. The mean metabolic rate (MRG1u) for meningiomas was 0.26 ± 0.13 mikromol/g/min (range 0.08–0.62 mikromol/g/min).

The authors report their experiences gained from 19 patients with ventral or ventrolateral foramen magnum meningiomas operated on via the dorsolateral, suboccipital transcondylar access route. It is emphasized that the microsurgical management of these lesions includes two important aspects which increase the safety of the procedure: a meticulous preoperative planning based on the microanatomical details of each patient, as well as an individualized tailoring of the surgical approach. There were no deaths, and, in the past 5 years, no neurological complications in this series. Gross total removal of the tumour was achieved in each case. It is concluded that microsurgical removal of ventral or ventrolateral foramen magnum meningiomas with this technique constitutes a safe and recommendable procedure.

The glucose metabolism of 62 meningiomas was measured by fluorine -18-2-fluorodeoxyglucose (FDG) PET and correlated with proliferation rate (Ki-67 index) and tumor cellularity. The mean metabolic rate (MRGlu) for meningiomas was 0.26 +/- 0.13 mikromol/g/min (range 0.08-0.62 mikromol/g/min). The relative tumor FDG-uptake (Q-MRGlu) (tumor/contralateral cortex) of all meningiomas was calculated with 0.73 +/- 0.37 (0.24-1.79). Differences of Q-MRGlu were significant between the groups with high vs. low cellularity (p0.01), increased vs. normal proliferation rate (p0.025) and low (WHO grade I) vs. higher (WHO grades II, III) graded tumors. In recurrent meningiomas (14 tumors) the glucose metabolism was not increased. The data show that 18 FDG-PET is suitable to serve as non-invasive predictor of tumor growth characteristics in meningiomas.

Selection of the approach and technique for surgical repair of aneurysm of the vertebrobasilar artery system is mainly based on angiographic features. This report emphasizes that planning the surgical procedure should also include preoperative evaluation of the individual skull base configuration, as well as the relationship between aneurysm site and surrounding bony structures. These features are evaluated on thin slice CT scans using bone tissue algorithms and are particularly important for adequate exposure of distal vertebral artery (VA) or midline aneurysms, because these cases require drilling of the jugular tubercle. For the use of lateral approaches, the surgeon must be familiar with the extradural and intradural anatomy of the foramen magnum region and may rely on at least five anatomical landmarks for orientation during surgery: 1) the dural entrance of the vertebral artery; 2) the posterior condylar emissary vein; 3) the medial rim of the distal sigmoid sinus; 4) the hypoglossal canal; 5) the jugular tubercle. To increase the safety of the procedure, the authors recommend an individualized tailoring of the surgical approach according to the variable morphological situation of each patient.

Fourty-one surgically treated cavernomas of the basal ganglia and insula (15 cases), the midbrain (6 cases), the pons (12 cases), medulla oblongata (1 case) and spinal cord (7 cases) are presented. Surgical morbidity was mainly caused by lesions in the region of the approach if the cavernoma did not have contact to the pial or ventricular surface or by inadvertent occlusion of small perforating arteries or accompanying venous anomalies. The most problematic cases were basal ganglia cavernomas with surgically (vascular) induced capsular deficits. Four out of 5 patients with a fair to poor outcome due to surgical complications belonged to this group. The other had a midbrain cavernoma. The overall results (GOS) were good in 29 patients, fair in 8 and poor in 4. No patient died. Compared to the risky spontanous course, the calculable risk of surgical treatment can be accepted as one treatment principle.

The occurrence of nosocomial infections in 1017 consecutive patients seen in a neurosurgical intensive care unit (ICU), over a period of 18 months is reported. The frequency of infections is low, which may possibly be due partly to the short stay in the ICU. Close interdisciplinary cooperation is stressed as an important factor in limiting infections. BACKGROUND. The aim of this study was to analyse the nosocomial infections in a neurosurgical intensive care unit over a period of 18 months, emphasizing localization and cause of infection, in order to adapt treatment and to take preventive measures. From 15% to 27% of patients treated in ICUs acquire nosocomial infections. In Germany this means 500,000-800,000 patients a year, and the annual costs related to nosocomial infections are estimated at 1.7 billion Deutschmarks. PATIENTS AND METHODS. In all, 1017 consecutive patients were evaluated. The patients were divided into two groups, depending on the duration of treatment in the ICU: Patients who remained for less than 48 h (1017 patients) Patients who were treated for a period exceeding 48 h (314 patients) The evaluation was performed retrospectively from the medical documentation. Criteria for registration are those of the Centers for Disease Control (Atlanta 1988). When more than one infection was diagnosed, each was considered as a new infection, regardless of the bacteria involved. Among the 314 patients who were in the ICU for more than 48 h a total of 114 nosocomial infections were recorded. The frequency of infection referred to all patients treated during that time (n = 1017) was 11.2%, while the frequency among those who were treated for longer than 48 h was 36.3%. Most infections (38.6%) affected the respiratory tract, followed by infections of the urinary tract. Of the bacteria determined 56.7% were gram-negative. In this group E. coli was the most frequently found (29.8%). In the group of gram-positive bacteria, S. aureus was diagnosed in 56.3% of cases. Twelve (16%) of the infected patients died and lethality referred to all patients was 8.6%. DISCUSSION. Compared with other studies, this study revealed a low the infection rate, at 11.2%. This can be explained partly by the short stay in this ICU (mean 3.7 days) and partly by the retrospective method of registration and the particular medical characteristics of neurosurgical patients. The well-known general risk factors for infection, such as age, mechanical ventilation, continuous catheterization of the bladder, and long duration of stay, are also found in neurosurgical ICUs. It is quite difficult to determine to what extent nosocomial infections prolong the treatment necessitated by the primary neurosurgical disease. We were not able to extrapolate the influence of immunosuppressant treatment on the appearance of nosocomial infections, as almost all patients in this study were receiving steroids. This study underlines the necessity of interdisciplinary cooperation between neurosurgeons, anaesthesiologists, microbiologists and nurses in neurosurgical ICUs, where most patients staying longer than 48 h are immunosuppressed and ventilated and thereby particularly at risk of nosocomial infections.

The etiology of the endocrine orbitopathy is still unknown and thereby their treatment remains symptomatic. The surgical decompression is achieved in resecting lateral wall, roof and partly bottom of the orbit. We treated 23 eyes in 14 patients and in only one patient the decompression obtained with this method was insufficient. This patient underwent additionally transantral transethmoidal decompression. One patient had a complete loss of vision after surgery probably due to direct lesion of the optic nerve. The decompression of the orbit is indicated in fast progressive endocrine orbitopathies with impairment of the visual function.

Der selten benutzte Begriff simultane „Neuro-Rhinochirurgie“ besagt, das die multidisziplinare, neurochirurgisch-Hals-Nasen-Ohren-arztliche operative Behandlung von bestimmten, fachuberschreitenden Erkrankungen nicht zweizeitig und getrennt nach Fachgebieten, sondern gleichzeitig in einer Narkose gemeinsam erfolgt. Damit ist weniger gemeint, das die Vertreter beider Fachdisziplinen gleichzeitig arbeiten, vielmehr, das beide abwechselnd aktiv werden und der jeweils andere assistiert und berat. Ob die Grenzgebiete der einzelnen Facher dabei uberschritten werden, spielt keine Rolle, da es sich im Prinzip um einen gemeinsamen Eingriff handelt, fur den aber mehr als das Fachwissen einer Disziplin notwendig ist.

Carotid ophthalmic artery aneurysms are of special interest because the direct microsurgical clipping procedure requires a special surgical strategy and technique. Worthy of mention are temporary internal carotid artery (ICA) occlusion in the neck, temporary clipping of the carotid artery near the cavernous sinus, retrograde or direct evacuation of the aneurysm, special (fenestrated) clips, removal of the clinoid process and the roof of the optic canal, and precise knowledge of the anatomy in the cavernous sinus and the relationship of the clinoid process to the internal carotid artery.

Five years ago, we changed our policy regarding the treatment of cerebral arteriovenous malformations (AVMs) from a purely surgical technique to a combined procedure with preoperative embolization and operation. Since then, the number of operations on AVMs has decreased. One reason for this is the fact that some AVMs are still under neuroradiological treatment; another may be that in some cases the neuroradiologist was able to completely occlude the malformation. One further reason could be the lack of information on how effectively embolized but still active AVMs can be surgically treated. This article is intended to contribute to some aspects of the problems encountered during surgery on embolized AVMs and to the final result after surgical removal of an incompletely embolized AVM.

A European, multicenter, prospective, randomized, double-blind, dose-comparison study on preventive therapy with intravenously administered nimodipine was performed to evaluate the efficacy and tolerability of two different doses: 2 and 3 mg/h. Two hundred four patients fulfilled the criteria for enrollment in the study: surgery within 72 hours after the last subarachnoid hemorrhage, and age between 16 and 72 years. All patients who had Hunt and Hess grades of I to III were operated upon; patients who had poor Hunt and Hess grades (IV-V) were operated on according to the surgeon's choice. This treatment regimen was associated with a low incidence of delayed neurological dysfunction with no significant difference between the two dosage groups: three patients (1.5%) remained severely disabled and two (1%) moderately disabled due to vasospasm with or without additional complications. Among the patients with Hunt and Hess grades of IV or V, the long-term outcome was favorable (good-fair) for 40% and unfavorable for 60%. Among the patients with grades of I to III, the long-term outcome was favorable for 89% and unfavorable for 11%.