Zentralblatt Fur Neurochirurgie最新文献

Background: Virtual endoscopy (VE) is a new and promising imaging technology. Applied to neuroendoscopy it allows preoperative simulation of a procedure and evaluation of the individual intraventricular anatomy in selected cases. Along with neuronavigation and real time intraoperative imaging, VE is expected to improve the safety and efficacy of neuroendoscopic procedures.

Patients and methods: Between April 2003 and February 2004 VE simulation was performed in 13 randomly selected patients subjected to endoscopic procedures. Pathological entities included 4 cases with aqueduct stenosis, 4 with suprasellar arachnoid cysts, 2 tumors of the posterior third ventricle, 1 colloid cyst, 1 hyperplasia of the choroid plexus and 1 case with multiloculated hydrocephalus due to intraventricular septations. In 8 patients VE was accomplished preoperatively, in another 5 it was done after the operation, using data sets from neuronavigation imaging planning in 4 patients, and in one case using postoperative imaging studies. T (1)-weighted 3D image sets were acquired on a 1.5 T GE Genesis SIGNA MR scanner and VE reconstruction was performed using the General Electric Navigator software. The VE images were compared with the real images obtained during the endoscopic procedures and evaluated for their impact on the planning of the operative approach.

Results: VE implementation succeeded in all 13 patients. Major neuroanatomic reference structures were easily recognizable in all cases. Membranous structures such as the thinned floor of the third ventricle or cyst walls were identifiable in only 46 % of the cases. In 6 cases (46 %) VE showed anatomical variants and details relevant for the endoscopic procedure that were not identified on conventional MR images.

Conclusions: VE has proved to be an important adjunct to the preoperative planning of neuroendoscopic procedures and its routine application is suggested.

Object: Traumatic delayed epidural hematoma (DEH) can be defined as a hematoma that is insignificant or not present on the initial computerized tomography (CT) scan made after trauma but subsequent CT scan shows sizeable epidural bleeding. During a 3-year period we have treated a total of 96 epidural hematomas, eight (8.3 %) of which had a delayed onset.

Case report: We present here an analysis of the eight patients with traumatic DEH which had a significant mass effect in all patients and required surgical evacuation. In three patients with mild head injury (GCS > 12) neurological deterioration indicated the necessity of repeating the CT scan and preceded the detection of DEH. In only one case of the five patients with moderate (8 < GCS < 13) and severe head injury (GCS < 9) was neurological deterioration the precursor of the DEH. All patients were immediately operated on after diagnosis. Postoperative outcome was favorable in all cases.

Conclusions: DEHs are highly unpredictable and continue to cause diagnostic difficulty. Close observation for signs of clinical deterioration and repeat CT scan are the most important factors for early detection of DEH. Early diagnosis and prompt operation offers excellent results for DEHs.

Diffuse astrocytomas, oligodendrogliomas, and oligoastrocytomas (mixed gliomas) WHO grade II, pleomorphic xanthoastrocytomas (PXAs), pilocytic astrocytomas, and subependymal giant cell astrocytomas (SEGAs) are often referred to as low-grade gliomas. WHO grade II astrocytomas, oligodendrogliomas, and mixed gliomas are characterized by their infiltrative growth, frequent tumor recurrence and a more than 50 % risk for malignant progression. In contrast, pilocytic astrocytomas and SEGAs are circumscribed tumors amenable to a (radio)surgical cure. There are few universally accepted guidelines for the treatment of low-grade gliomas. In this review, three neurosurgeons, a neurologist, a neuropathologist, and a radiation oncologist discuss some of the difficult issues surrounding the diagnosis and treatment of low-grade gliomas from their individual points of view (i. e., classification and neuropathology, MR imaging, stereotactic biopsy, microsurgery, interstitial radiotherapy/brachytherapy, radiotherapy, wait and see strategy).

The authors report on a 69-year-old man presenting with progressive leg weakness and gait ataxia over two years. A central intramedullary cord lesion ranging from T8-12 on MR imaging was misdiagnosed as a low-grade glioma and a biopsy was attempted followed by temporary clinical deterioration. Selective spinal angiography revealed a spinal dural arteriovenous (AV) fistula on the left L3 nerve root sheath despite the absence of pathological vessels on MR imaging. The fistula was successfully treated by microsurgical interruption of the arterialized intradural vein. The present case should remind us to include selective spinal angiography in our diagnostic work-up in patients predisposed for spinal dural AV fistula by male sex, advanced age and clinical presentation of slowly progressive sensorimotor symptoms with myelopathy on MR imaging, even in the absence of any pathological vascular structures.

Introduction: Blood pressure management in patients undergoing surgery for clipping of aneurysms is demanding. More information about the ability of cerebral vessels to normally regulate cerebral blood flow may have a direct influence on the intraoperative management. In patients with subarachnoid hemorrhage (SAH) a disturbance of cerebral autoregulation has been reported and it correlated with the severity of the bleeding in these studies. The impairment of autoregulation was demonstrated using static measurements of cerebral pressure autoregulation. However, the dynamic component of the autoregulatory capacity seems to be of importance in the acute setting after SAH. The aim of this study was to evaluate dynamic pressure autoregulation in patients undergoing surgery for intracranial aneurysms.

Patients/material and methods: 36 patients with a mean age of 45 years were evaluated, 26 patients with acute SAH, 10 patients with unruptured aneurysms. Cerebral autoregulation in normocapnia was tested using thigh cuffs to alter arterial blood pressure and continuous registration of the blood flow velocities with transcranial Doppler sonography. After the induction of general anesthesia under normocapnia the autoregulatory index (ARI) was calculated (values between 0-9). Patient groups were compared using Wilcoxon- and Spearman's rank test.

Results: The two patient groups were comparable with regard to gender, age, PaCO(2), blood flow velocities and blood pressure. In patients with SAH mean ARI was 3.1/3.3 (right/left side) compared to 4.7/4.6 (right/left side) in patients without SAH. The difference was statistically significant (Wilcoxon p = 0.0399). The degree of impairment of the autoregulatory capacity increased significantly (p = 0.006) with the severity of the SAH (Hunt&Hess and Fisher scale).

Conclusion: Dynamic pressure autoregulation is impaired in patients after SAH compared to patients without SAH and correlates with the severity of the SAH. We propose that autoregulation should be measured in all patients with SAH or that an impaired autoregulation should be taken into account in patients with SAH undergoing surgery in the acute phase.

Objective: After the implementation of the G-DRG system in Germany, doubts arose whether and how interdisciplinary pain therapy centers should be restructured to remain profitable and maintain medical excellence for patients with a long ordeal of malaise.

Methods: To reveal structural deficits, we performed a detailed economic analysis of all patients treated at an interdisciplinary pain therapy center of a German University hospital in 2004.

Results: 3,672 patients were treated: 2,163 outpatients, 753 at the daycare clinic, 619 as consults and 132 inpatients. The costs for personnel were euro 736,645, consumables euro 105,061, and infrastructure euro 277,762. We calculated fixed costs of euro 236, and consumables of euro 24 per patient. The costs for surgery were euro 1,595, and for a neuroradiological examination euro 245 per patient. Overall treatment costs were euro 319 per patient. We calculated an overall loss of euro 476,752 or euro 109.19 per patient. Outpatients caused a total loss of euro 456,665.83 or euro 211 per patient, consults a total loss of euro 161 683.16 or euro 261.20 per patient, daycare patients a slight profit of euro 30,370 or euro 40 per patient and inpatients a total profit of euro 111,225 or euro 135 per day.

Conclusion: Managerial optimization can yield considerable cost reductions in the G-DRG coding system, without any change in treatment strategies, selection of profitable patients or dismissal of personnel. Inversely, additional personnel are needed to accomplish the implementation process. Board certification was unveiled to constitute the key structural implementation that ensures the economic survival of the department and continuing medical excellence for the patients.

Introduction: Since intracerebral hemorrhage (ICH) is frequently associated with intraventricular bleeding (IVH), we sought to detect cranial computed tomography features that would indicate early on in the patient's history the development of chronic hydrocephalus with a permanent need for cerebrospinal fluid (CSF) diversion.

Methods and materials: A total of 25 consecutive cases presenting with ICH/IVH was studied retrospectively. Outcome was assessed using the Glasgow Outcome Scale at an average of 8 months subsequently. Diagnosis of ICH/IVH and (acute) hydrocephalus was made by early cranial CT scanning employing a selection of radiological criteria according to the literature including the Evans ratio. All patients then received external ventricular drainage. Chronic hydrocephalus was diagnosed by intraventricular pressure monitoring or by cranial CT follow-up after removal of the external drainage.

Results: None of the radiological criteria nor the scores obtained differed between the two groups. However, the ratio of scores for IVH/ICH was higher among the patients who developed a chronic hydrocephalus. All other parameters including volume of ICH and IVH were equally distributed. Overall outcome was poor with a median GOS score of 3.

Conclusions: The ICH/IVH ratio presented here can be interpreted as an individual measure of propensity to impairment of CSF circulation. Further studies on larger populations will be needed to show whether this can be employed as an early diagnostic criterion with respect to chronic hydrocephalus.

True metastatic disease to the orbit is rare. We present an overview of the treatment and clinical outcome of 11 orbital metastases, carried out in our center from 1995 to 2002. The surgical approach was determined by the location and type of the lesion. The most common primary cancers that metastasized to the orbit were lung cancer, and breast cancer. In 6 patients, there was no history of cancer and in 1 patient the primary site remained obscure despite systemic evaluation. Three patients showed recurrent tumor growth despite chemo- and/or radiotherapy. The mean survival time was 15 months after diagnosis of orbital metastases. The systemic prognosis is generally poor. A multidisciplinary treatment is required. Therapeutic options include surgical biopsy, debulking or excision, hormonal therapy, chemotherapy, and radiation therapy.

Objective and importance: The authors present a rare case of a primary cranial vault lymphoma, mimicking a subacute subdural hematoma after head trauma.

Clinical presentation: A 78-year-old woman was admitted to the hospital with progressive left hemiparesis, headache and a gradually increasing soft lump over the right parietal region 1 week after head trauma due to falling from a high place. A computed tomography (CT) scan demonstrated a hyperdense parieto-occipital subdural and subgaleal lesion together with marked midline shift and white matter edema.

Intervention: Considering her trauma story and clinical progression, the patient underwent an emergency operation with the diagnosis of subdural hematoma. However, the lesion was found to be of a tumors nature and the histopathological diagnosis was high-grade malignant non-Hodgkin's lymphoma.

Conclusion: The authors emphasize the rarity of primary cranial vault lymphoma and its importance in the differential diagnosis of cranial vault mass lesions extending either intra- or extracranially. This case may be considered as another example where magnetic resonance imaging (MRI) is the ultimate definitive test in the emergency ward whenever CT demonstrates any findings which are unclear.