Zentralblatt Fur Neurochirurgie最新文献

Background: The incidence of clinically silent meningiomas in 75-year-old individuals was determined five years ago in the Vienna Transdanube Ageing Study (VITA). At the time a watch-and-wait approach was recommended in cases of incidentally discovered meningiomas.

Methods: 420 out of the initial cohort of 532 test persons underwent control investigations after 2.5 and 5 years. Six of the nine known tumors were measured again and the patients underwent clinical, neurological and psychological tests. Changes in tumor size were determined and all new tumors seen on MRI investigation were carefully reviewed.

Results: Tumor growth was minimal in all six cases that were followed over the entire period. Two of the original meningioma patients had died and one patient had undergone tumor resection.

Conclusions: The watch-and-wait approach recommended after the VITA study was confirmed by the present investigation. Tumor growth was slow in all cases; no clinical symptoms have been registered thus far. The intervals between control investigations may even be prolonged depending on the location of the tumor. In this age group the operation appears to pose a greater risk than the presence of an asymptomatic tumor.

Spinal dumbbell tumors originate from nerve roots, usually growing within the spinal canal, the neural foramen and the extraforaminal compartment in the paraspinal region. We report a case of a 20-year-old man who presented with back pain radiating to his left lower limb mostly when in a supine position. Magnetic resonance imaging of the lumbar spine showed a dumbbell lesion at the L5-S1 neural foramen, with enlargement of the foramen and extension into the left paraspinal compartment. Although MR imaging studies were strongly suggestive of a dumbbell radicular schwannoma, the histological diagnosis was an osteoblastoma of the lumbar spine originating from the left L5 pedicle with intracanalicular, intraforaminal and extracanalicular extension. The presentation, imaging studies, intervention, pathology and differential diagnosis are described.

The authors present a case of 44-year-old Caucasian female diagnosed with meningothelial meningioma 40 years after radiotherapy for sporadic unilateral retinoblastoma. The genetic analysis of DNA from the meningioma revealed no oncogenic mutation in the RB1 gene. The analysis of meningioma cells by flow cytometry revealed the following immunophenotype: vimentin++ CD56+ GFAP- EGFR-. Intermediate intensities of Her-2/neu and Pgp expression were detected in a small percentage of tumour cells. Data suggest that the tumour was most likely induced by radiotherapy and did not arise as a second tumour as there was no hereditary predisposition to retinoblastoma.

Background and objectives: The initial response of trigeminal neuralgia to medication is about 69%. However drug therapy is ineffective in 25% of patients and about 8% become drug-intolerant. These patients proceed to surgical interventions, which require constant appraisal to determine their efficacy and acceptability. The purpose of this study was to evaluate the long-term outcome of surgical interventions for trigeminal neuralgia to offer a guide to patients and surgeons when choosing the right procedure for the appropriate patient and to investigate the effects of patients' and surgeons' preferences on the outcome.

Patients and methods: The study design was consecutive case review. Participants were 256 consecutive patients with refractory trigeminal neuralgia, who underwent 405 surgical procedures to control trigeminal neuralgia. The main outcome measures were: the response rate, time to pain recurrence and surgical complications. 172 were fit for microvascular decompression (MVD), glycerol injection (GI) or radiofrequency thermocoagulation (RF) and were offered the choice between the three procedures; 95 went for MVD and 77 underwent either GI or RF. The choice between GI and RF was a surgical decision.

Results: The 3-year success rate was 54.8% in patients who underwent GI and 70.7% in patients who underwent percutaneous RF. In contrast 85.6% of patients who underwent MVD remained pain-free at 3 years. The complication rate following these surgical interventions was relatively low with no deaths.

Conclusions: Surgical intervention for the treatment of refractory trigeminal neuralgia is effective and safe and should be considered in patients after failed medical therapy. Whilst MVD offered the best long-term outcome in this series, percutaneous GI or RF offered a safe and reliable alternative for those who chose to undergo these procedures.

The occurrence of a hemorrhage into a vestibular schwannoma is a rare phenomenon. Several reports, however, indicate a risk profile for a subgroup of patients with vestibular schwannoma which show hypervascularity in the histopathological examination. Cystic formation, large size, mixed Antoni type and anticoagulation therapy seem to enhance the risk of tumor hemorrhage. We report on a patient with a large cystic vestibular schwannoma who died from fatal bleeding into the tumor 15 months following stereotactic radiation therapy. Since hemorrhage seems to be a relevant risk in large cystic vestibular schwannomas, a surgical treatment should be preferred whenever possible.

The clinical case of a 34-year-old patient is presented who was diagnosed with Ewing sarcoma in the right pedicle of the L5 vertebral body on the basis of persisting dorsolumbar pain. Staging examinations including CT scan of the thorax and abdomen as well as bone scintigraphy were inconspicuous. The patient underwent 6 cycles of neoadjuvant chemotherapy (VIDE, similar to Euro Ewing 99). Presurgically, embolisation of the L4 and L5 vertebral bodies was performed on both sides. The tumour was removed via a dorsal approach with corporectomy of L5 and resection of the right nerve root of L5. The defect was bridged by a titanium cage filled with bone cement; a dorsal L4-S1 instrumentation was performed. Early postoperative X-rays showed a screw dislocation in S1, making a revision intervention and screw replacement necessary. For additional fixation, S2 was instrumented. Histopathology classified the tissue samples as containing no active tumour cells. Surgery was followed by additional chemotherapy. The patient has remained free of recurrence until now. The aim of this case report is to call attention to the unusual site of the Ewing sarcoma as well as to discuss therapy options, especially dorsal corporectomy, and the prognosis together with a review of the most current literature.

The case of a 60-year-old man with a 6-month history of cerebrospinal fluid (CSF) rhinorrhea is presented. Computed tomography (CT) and magnetic resonance (MR) imaging revealed an intrasphenoidal mass extending through a bony defect of the roof of the left sphenoid sinus. Transnasal surgical repair was performed; intraoperatively the mass was identified as an intrasphenoidal encephalocele. The pathogenesis of this anomaly is analyzed, the clinical findings and the operative treatment are described, and the literature is reviewed.

Object: This study proposes a topographical classification of spheno-orbital meningiomas. Its aim was to define whether the different intraorbital localizations require different surgical approaches and have different recurrence rates and outcomes.

Material and methods: Sixty patients with spheno-orbital meningiomas operated upon between 1983 and 2003 were reviewed. Four types were identified according to the extent of intraorbital tumor invasion: I: lateral or superolateral (15 cases); II: medial and inferomedial (8 cases); III: orbital apex (25 cases); IV: diffuse (12 cases). Three surgical approaches were used: lateral orbitotomy (15 cases with lateral or superolateral tumors), supraorbital-pterional approach (42 cases, including all 8 inferomedial cases, all 25 orbital apex cases, and 9 of 12 diffuse tumors), and a fronto-temporal-orbitozygomatic approach (only 3 cases with diffuse meningiomas and large-scale tumor invasion in the infratemporal fossa and cavernous sinus).

Results: Tumor removal was complete (Simpson grades I and II) in 40 cases, and incomplete in 20 (33.3%). There were two postoperative deaths (3.3%). A sufficient clinical follow-up was obtained in 52 cases. The clinical outcome was excellent in 26 patients (50%), good in 16 (30.8%), moderate in 6 (11.5%), and poor in 4 (7.7%). Twenty-two of 52 patients (42.3%) had tumor recurrence; however, 44 (84.6%) achieved tumor control after surgery alone through two or more operations. The recurrence rate was correlated with the Simpson grade of resection and the intraorbital tumor location. Significantly higher rates of recurrence were recorded for the orbital apex type (50%) and diffuse forms (60%), than for the inferomedial (28.5%) and superolateral forms (23%).

Conclusions: Spheno-orbital meningiomas may be classified according to the location and extent of the intraorbital tumor invasion. The different localizations may require different surgical approaches, with different chances of complete removal. The location and extent of the intraorbital tumor results in different recurrence rates, lower for superolateral and inferomedial forms than for orbital apex and diffuse forms.