Zentralblatt Fur Neurochirurgie最新文献

Background: Intradural extramedullary cysts are a rare cause of spinal cord compression. We present a case with slowly progressive radicular pain and gait disorder over several years, due to medullary compression by a giant cervico-thoracic arachnoid cyst.

Case report: A 65-year-old man presented with progressive pain irradiating from the lower back to the waist and both legs over a period of 2 years. Neurological examination revealed a decreased sensation for pain, vibration, and proprioception below T7, without muscle weakness. Reflexes were increased in both lower extremities, with bilateral extensor plantar responses. The MRI showed an intradural extramedullary lesion, suggestive for an arachnoid cyst. The spinal cord was displaced and compressed anteriorly, with a smallest diameter of 1 mm. Surgical resection of the cyst resulted in decompression and re-expansion of the spinal cord as visualized with MRI. Neurological examination 6 months after surgery revealed nearly complete recovery of neurological deficits.

Discussion: This case report, together with a review of the literature, shows the extreme adaptability of the human spinal cord, in cases of slowly progressive compression.

Objective: Postoperative monitoring of the electrode position is important to evaluate the best stimulation site in deep brain stimulation. MR imaging is excellent for ruling out postoperative complications e.g. haemorrhage, but its accuracy in electrode localisation is still controversial. The reasons for this are the size of the artefact around the electrode and its unclear relation to the electrode position (concentric or eccentric). The goal of this study was to determine the relation and size of these artefacts to the electrodes by comparing the position of the electrodes in postoperative MR and CT imaging.

Material and methods: Five patients underwent deep brain stimulation of the subthalamic nucleus due to levodopa-induced motor complications in Parkinson's disease. A stereotactic CT and a non-stereotactic MR were performed for postoperative localisation of the electrode position. The stereotactic MR for planning of the trajectories and targets was done under general anaesthesia. The latter two were fused to the stereotactic MR and the position of the DBS electrode contacts was determined on CT and MRI. The size of the artefact was measured at the level of each contact in two directions, anterior to posterior (AP) and lateral. Altogether 40 contacts were evaluated.

Results: Mean size of the CT-artefact was 2.6 mm AP (range, 2.0-3.2 mm) and 2.6 mm laterally (range, 2.0-3.8 mm). In comparison, mean size on the MRI was 3.5 mm AP (range, 2.9-5.3 mm) and 3.8 mm laterally (range, 2.9-4.8 mm). A trajectory with a 1.2 mm diameter (size of the DBS electrode) was centred on the electrodes' artefact of the CT and the MRI. The difference between the contact coordinates was calculated as deviation of the artefact around the electrode on the MR. Mean deviation was 0.2 mm on the x-axis (range, 0-0.5 mm), 0.5 mm on the y-axis (range, 0-1.1 mm) and 0.3 mm on the z-axis (range, 0-0.7 mm). There were no significant differences (t-test, p > 0.4).

Conclusion: The size of the electrodes' artefact was smaller on CT compared to MR. Furthermore, the position was not precisely concentric around the electrode. Nevertheless, the mean deviation after measuring the contact position in both CT and MR was less than 1 mm in all three planes. Both techniques are eligible for postoperative localisation of DBS electrodes, with a small imprecision of the non-stereotactic MR compared to the stereotactic CT. This might be compensated by the fact that postoperative MR can rule out asymptomatic postoperative complications e.g. haemorrhages or infarctions, without radiation exposure of the patient.

Objective: Although there is a tendency to minimize the surgical procedures for chronic subdural hematomas, there is no agreement on the optimal treatment. In the literature there is only one published result of a randomized study comparing twist drill craniostomy with burr-hole craniostomy. We aimed to compare twist drill craniostomy with burr-hole craniostomy for the treatment of unilateral hemispheric chronic subdural hematomas in adults.

Material and methods: The study was planned as a prospective, randomized, controlled investigation. Between November 2002 and April 2006, 70 patients (54 male and 16 female) with unilateral hemispheric chronic subdural hematomas were operated. 32 patients underwent burr-hole craniostomy and 38 patients were treated by twist drill craniostomy. After discharge, the patients were followed up at 1, 3 and 6 months after operation. Mortality, morbidity, surgical complications requiring reoperation, duration of hospitalization, recurrence, total number of reoperations, and cure rates were compared.

Results: Two patients died and one patient developed 6th nerve paresis in the inpatient period. There were three recurrences (two in the burr-hole craniostomy group, one in the twist drill craniostomy group) and in one patient from the burr-hole craniostomy group a chronic subdural hematoma developed on the contralateral side postoperatively. There was no significant difference clinically and radiologically between the two groups at any time period.

Conclusion: Both surgical methods seem effective for the treatment of unilateral chronic subdural hematomas.

Objective: Perineuriomas are rare benign peripheral nerve sheath tumors, which have only been included in the WHO classification system since 2000. They are divided into intraneural perineuriomas and soft tissue tumors. Intraneural perineuriomas were previously known as localized hypertrophic neuropathies. Because of their rarity there are only case reports in the literature.

Methods: Between 1992 and 2006 surgery was performed on four patients suffering from intraneural perineuriomas in our hospital. All patients were males, aged five, ten, twenty and twenty-nine years old. One of the tumors occurred in the ulnar nerve, one in the common peroneal part of the sciatic nerve and two of them in the radial nerve. In a retrospective study the clinical, electrophysiological and imaging data of the patients was analyzed. Two of these patients had previously been treated with decompression and neurolysis of the nerve for the suspicion of a nerve compression syndrome. Revisions were necessary following progressive neurological deterioration postoperatively. Explorations of the nerves showed nerve tumors. The tumors were resected and nerve grafting was performed.

Conclusions: These tumors tend to affect the nerves of the upper extremities in children or young adults. The predominant symptom is a slow-progressive paralysis. Two of the four patients showed a partial improvement of their motor and sensorial nerve deficits in the long-term follow-up following complete tumor resection and interpositional autologous nerve grafts. No relapse could be observed. In cases of slow-progressive neurological deficits of a peripheral nerve in young patients the differential diagnosis should include the intraneural perineuriomas.

Aims/objectives: It has been previously recognized that the anatomy of arterial bifurcations influences blood flow and has a significant role in the development of vascular disease.

Material and methods: In the present study, we measured the average diameters of the internal carotid (ICA), anterior cerebral (ACA), and middle cerebral arteries (MCA) in autopsy cases. We also calculated the outflow to inflow area ratios for four distinct age groups and for each gender, using 33 adult autopsies and 7 fetuses.

Results: The area ratios decreased with age in both male and female samples. The decrease in the male (30%, p<0.05) was greater than the decrease for the female (17%, p > 0.05). The average diameter of the ACA, MCA and ICA of both female and male cases increased up to the 25-44 age group, decreased for the 45-64 age group, with a second increase above the age of 65.

Conclusions: The decrease in the area ratios and the pattern of changes of the dimensions of the cerebral vessels with age are useful to examine the causal relationships of these pathologic conditions and raises novel questions about age and gender differences in the structure of the intracranial vessels.

Background: The association of Charcot-Marie-Tooth (CMT) disease and trigeminal neuralgia (TN) is rare. CMT and bilateral TN is even rarer. Our literature review has revealed only 4 previous cases with CMT and bilateral TN. We report the case of a 23-year-old man with a prior diagnosis of CMT and unilateral deafness who initially presented with excruciating and lancinating right-sided facial pain.

Patient and method: Initially treated with percutanous ablation elsewhere with only short-lasting relief, the patient was on toxic doses of medication when he presented to us. Neuro-imaging using magnetic resonance imaging showed vascular compression as the possible cause of pain. At initial surgery, two artery loops were found compressing the right nerve superomedially and an artery and a vein was found compressing the nerve inferomedially. Relief was instantaneous and for 1 year there was no recurrence of right facial pain. Left-sided pain which had been minimal before microvascular decompression (MVD) became intolerable immediately after right-sided surgery, yet responded to mild doses of carbamazepine for almost a year. At one year, the patient had to undergo MVD for the left trigeminal nerve with complete relief over both sides of his face without any medication.

Results: The patient remains pain-free on both sides at 1-year follow-up after the second MVD.

Conclusions: The underlying neuropathy in CMT makes the trigeminal nerve more vulnerable to vascular compression than usual. The bilateral compression of the trigeminal nerve-pons junction in our patient suggests that the external pressure probably adds to the internal defects in central myelin formation, structure or maintenance. Nevertheless, the mid-term follow-up after MVD clearly shows that the causal treatment for TN can be successfully applied to patients with TN plus CMT.

Although less frequent than lumbar degenerative disc disease, cervical disc disease may be much more neurologically compromising due to anatomical particularities. Since its first description together with the typical signs and symptoms the operative therapy of cervical disc disease has undergone a changeful evolution over the years. The frequent shifts of paradigms in treatment are particularly noticeable compared to other neurosurgical diseases. Initially, the dorsal decompression of neural structures (laminectomy) with a more or less invasive posterior approach (posterior foraminotomy) was the primary aim of the operation. Because of anatomical limitations, a paradigm shift occurred in the middle of the last century, favouring an anterior approach and discectomy, without and with implantation of various spacers (arthrodesis). A large variety of different materials and designs for these implants as alternatives to autologous iliac crest bone were established, all with the aim of creating a solid fusion of the operated segment. Anterior cervical discectomy and fusion (ACDF), regarded worldwide as the "gold standard" for the treatment of cervical disc disease, was later complemented by modified, minimally invasive or endoscopic techniques using anterior and posterior approaches. The fear of adjacent level disease in the vicinity of a fused cervical segment led to another paradigm shift in the last few years, away from fusing procedures, towards new motion preserving technologies (arthroplasty) and back to minimally invasive dorsal techniques for the treatment of cervical disc disease. This article reviews the evolution of the operative treatment of cervical disc disease in the last 80 years, outlines the advantages and disadvantages of each approach and technique and focuses on the rationale of the paradigm shifts. Current established and alternative treatment concepts are illuminated and discussed together with the currently relevant literature.

Objective: Synovial cysts are an important differential diagnosis in lumbar radiculopathy.

Patients and methods: From 2000 to 2005, we treated 32 patients (22 female, 10 male) suffering from lumbar radiculopathy due to spinal synovial cysts. The mean age was 64 years (range 42-84). The clinical mix of cases at admission was: 10 patients with radiculating pain accompanied by sensory disturbances, 8 with neurogenic claudication, 7 with muscular weakness, 6 with radicular pain, and one with back pain only. The anatomical distribution was 10 cases at the L5/S1 level, 16 cases at L4/5, 5 cases at L3/4, and one case at L1/2. The average period from the first onset of symptoms to treatment was 9 months. Twenty-five cases were treated via a (limited) laminotomy only and 7 via hemilaminectomy. The cases were evaluated clinically at routine follow-up.

Results: After a follow-up of between six months and three years, 15 patients were free of complaints, 13 had improved markedly, while 3 had considerable remaining complaints. One patient developed an instability requiring spinal fusion. We observed a local recurrence at the same site in one patient and three cases of synovial cysts on the contralateral joint at the same spinal level.

Conclusion: The operative removal of a spinal synovial cyst is beneficial in terms of treatment of the nerve root compression. In the majority of cases, a (limited) laminotomy is sufficient as an approach.

Intraparenchymal pericatheter cyst is a rare complication of shunt surgery. It occurs as a consequence of increased CSF outflow resistance distal to a patent ventricular catheter. Treatment has traditionally consisted of shunt revision. We report on two such cases managed conservatively. The role of shunt revisions in cases with asymptomatic intraparenchymal pericatheter cyst is debatable.

Intracerebral haemorrhage (ICH) occurs mostly in the context of arterial hypertension, with typical localisations. Tumour-associated bleeding is the cause of 6-10% of ICHs, mostly from metastases. We present the case of a 40-year-old female admitted originally for neck pain of sudden onset, accompanied by nausea and marked right arm paresis. A CT-scan revealed left fronto-central cortico-subcortical haemorrhage. Cerebral angiography was normal. Two months after the initial event the residual paresis worsened and the patient developed neuropsychological deficits. A CT-scan showed oedema around the original bleeding site, on MRI a solid lesion with a diameter of 5 cm could be seen, with some cystic alterations and contact to the meninges. The tumour was surgically removed, and removal at the time was considered complete. Histological analysis proved it to be an embryonal rhabdomyosarcoma. The patient's neurological deficits gradually improved. Almost three months after the operation she complained of intense left-sided headache. On CT a hyperdense left fronto-central lesion with positive enhancement could be seen; MRI confirmed a relapse tumour and showed bleeding in the rostral portion of the tumour as well as oedema. The patient started radiation therapy with a total dose of 60 Gy. Whole body image studies at the time failed to reveal any other neoplastic lesions. Two months later a CT-scan showed continued tumour growth. We present this case as a rare aetiology of intracerebral haemorrhage, more frequently associated with arterial hypertension or vascular pathology, as well as being an unusual manifestation of embryonal rhabdomyosarcoma, rarely found in the brain. The case also serves to illustrate the importance of a thorough diagnosis including MRI imaging in patients with so-called atypical ICH.