Zentralblatt Fur Neurochirurgie最新文献

Vascular malformations of the spinal cord and its meninges are rare diseases which comprise true inborn cavernomas and arteriovenous malformations (AVM), including perimedullary fistulae, glomerular and juvenile AVMs, and presumably acquired dural arteriovenous fistulae. This article gives an overview of the imaging features on magnetic resonance imaging (MRI) and digital subtraction angiography of both typical and atypical findings to describe the wide variety of possible pathological entities encountered. Clinical differential diagnoses, the neurological symptomatology and potential therapeutic approaches of these diseases, which may vary depending on the underlying pathology, are given. Although MRI constitutes the first choice diagnostic modality for suspected spinal vascular malformations, we conclude that the definite diagnosis of the disease and thus the choice of the appropriate therapeutic approach rests on selective spinal angiography which should be performed at a specialized center. Treatment in symptomatic patients offers an improvement in prognosis. Microsurgical treatment is recommended for symptomatic spinal cord cavernomas. Dural arteriovenous shunts can either be treated by microsurgical or endovascular approaches, the former being a simple, quick and secure approach to obliterate the fistula while the latter is technically demanding. In spinal arteriovenous malformations of both the fistulous and the glomerular type, the endovascular approach is the method of first choice; in selected cases, surgery or a combined therapy may be necessary.

Background and purpose: A prospective study was conducted to compare the neuropsychological outcome of surgical versus endovascular treatment in patients with cerebral aneurysms.

Methods: From April 2001 to 2005, 211 patients with ruptured cerebral aneurysms were treated at the senior author's institution. Of these 211 patients, 75 that were able and willing to undergo neuropsychological assessment 1 year after treatment of their aneurysm were enrolled in the study. Thirty-five patients were treated surgically and 40 by endovascular therapy. Standardized neuropsychological and personality tests were employed to assess cognitive and personality functions. One neurosurgical team using the same treatment protocols treated all patients.

Results: The two groups of patients did not differ significantly with respect to age, gender, concurrent diseases, Hunt and Hess grade, Fisher grade, frequency of complications, vasospasms and hydrocephalus development. No differences in performance on neuropsychological and cognitive tests (AVLT, TMT and WAIS-III) and personality variables and mood scales (TCI, BDI and SMS) were found one year postoperatively. If a full IQ as defined by WAIS-III and 1SD below the mean is considered as the main measure of cognitive deficits, 5.4% of the sample suffered from cognitive deficits. There were no differences between clipped and coiled patients (t=0.03; p=0.97).

Conclusions: The differences in the neuropsychological assessment of patients treated by either coiling or clipping were small and non-significant. Given the small number of patients in the study, however, we suggest the need for further research with a larger sample size and the use of a randomized design before drawing any firm conclusions.

Developmental venous anomalies (DVAs) are considered to be congenital anatomical variants of venous drainage. In most cases unspecific symptoms lead to their diagnosis. We describe a 35-year-old patient presenting with headache and dizziness. MRI was suspicious for arteriovenous malformation and the dorsal horn of the right lateral ventricle was enlarged. Digital subtraction angiography showed complex venous malformations with abnormal supratentorial venous drainage and bilateral cerebellar DVAs with associated varix nodes. This is a unique case of complex supra- and infratentorial abnormal venous drainage. After considering the complexity of these venous anomalies and the fact that the patient was asymptomatic there was no reasonable indication for treatment.

Background: The present study aimed to find radiological parameters that can provide indirect information on the invasive growth of meningioma relevant enough to predict the likely risk of postoperative neurological deficit.

Material/methods: The cohort consisted of 40 consecutive adult patients (from January 2004 till May 2005) with comparable general condition parameters (age 18-75 years, KRS 70-100, ASA 1-2) with meningiomas solely attacking brain tissue with the whole of their volume. The Pearson chi-square test was used for statistical evaluation.

Results: Radical resection of the meningioma was attained in 33 (82.5%) patients and subtotal resection in 7 (17.5%). Ten (25%) patients at 7 days after the operation had neurological findings which were worse than before. Seven were found to have a new neurological deficit and there were three cases of progression of the existing neurological symptoms. Three patients (7.5%) were worse off neurologically than before the operation as long as 3 months after surgery, while seven had their neurological condition restored ad integrum. All of the ten patients with postoperatively worsened neurological findings had their meningiomas localised in the eloquent area. A correlation was found between the eloquent area and neurological deficits, and also between the presence of peritumoral oedema (small, medium, large) and neurological deficits. Interdependence was detected between a discernible tumour-brain interface and the absence of oedema, between a discernible tumour-brain interface and a dural type of vascular supply, and between the dural type of vascularisation and an absence of oedema.

Conclusions: As follows from the outcomes, meningioma growth in the eloquent area and the presence of peritumoral oedema are the two adverse parameters predicting the development of postoperative neurological deficits. In contrast, dural types of vascularisation, a visible tumour-brain interface, meningioma growing in a non-eloquent area, and the absence of peritumoral oedema are favourable predictive parameters. To go by the results, in the presence of the last two parameters the patient need not be exposed to the risks of invasive selective angiography.

Objective: Peripheral nerve injuries are still underestimated. This study examines the outcomes after surgical treatment of traumatic nerve lesions of the upper extremities. The different surgical techniques are analyzed with regard to the long-term outcome.

Methods: This retrospective study presents the data of 93 patients (female: 24; male: 69) who were operated on for peripheral nerve injuries of the upper extremities in our department between 1991 and 2003. Mean age was 31 years (range, 5-67 years). Altogether 100 traumatic nerve lesions (ulnar nerve: 20; radial nerve: 22; median nerve: 25; axillary nerve: 6; accessory nerve: 7; musculocutaneous nerve: 2; long thoracic nerve: 1; digital nerve: 3; combined nerves: 7) were surgically treated. Surgical management included primary nerve suture in 16, neurolysis in 25, and nerve grafting in 59 patients.

Results: 74 patients (80%) were available for follow-up examination. The mean follow-up period was 35 months (range, 18-132 months). All patients up to the age of 20 years demonstrated good or excellent sensorimotor recovery. A good functional outcome was observed in 79% of the patients older than 20 years. Overall, good to excellent improvements of motor function were achieved for lesions of the musculocutaneous, radial, accessory and axillary nerves (100%, 89%, 100%, 100% functional useful muscle innervation, muscle recovery grade 3 and more). The length of grafts, in cases of secondary nerve reconstruction, did not influence functional outcome.

Conclusion: Generally, early surgical repair of a nerve lesion predicted a better outcome. A good functional motor recovery was dependent on the age of the patient. Traumatic nerve lesions, without signs of reinnervation, should be treated surgically within a period of three months after injury.

Background: Foraminal degenerative lumbar stenosis is traditionally considered a result of bony narrowing due to osteophytic appositions on the superior articular process. Clinical experience reveals that significant additional compression of the neural structures is due to degenerative hypertrophy of the adjacent ligamentum flavum. Therefore, microanatomical and neuroradiological investigations were performed to determine the microtopography of this ligament, especially with respect to its lateral extension.

Methods: Lumbar spine specimens of eight mid-aged human cadavers (mean age 34.5 years) were collected, and MRI studies with T1-weighted images were performed. The specially embedded specimens were sectioned horizontally at the level of the spinal ganglion (slice thickness: 2 mm). Anatomical morphometric data were correlated with identical measurements based on neuroradiological imaging and were analyzed statistically.

Results: The distance between midline and extraforaminal extension of the ligamentum flavum showed a mean value of 17 mm. The distance increased to 19 mm when the lateral insertion was correlated to the origin of the ligamentum flavum at the anterior margin of the lamina. The farthest lateral segment of the ligamentum flavum was determined in each case; it covered the synovial cavity of the lumbar facet joint in the direction of the extraforaminal segment of the intervertebral canal.

Conclusions: Measurements from mid-aged cadavers show the extent of the ligamentum flavum including its intra- and extraforaminal parts. Due to this anatomical situation a hypertrophic ligamentum flavum may contribute significantly to nerve root compression at the level of the lateral spinal recess. This has to be kept in mind during surgical decompression, which might be incomplete unless these hypertrophied parts are completely removed.

We report the rare case of a 74-year-old man who was admitted to our hospital with rapid progression of tetraparesis, which was most apparent in the lower right limb, sensory disturbances from C3 to S1 on the left side and recent onset of constipation and urinary retention. There was no known history of cancer. As MRI of the neck disclosed a cervical intramedullary mass lesion at C 4/5 level suspicious for a primary glial tumour, the patient underwent surgery. After microsurgical excision the histological analysis of the lesion unexpectedly revealed an intramedullary spinal cord metastasis (ISCM) of a poorly differentiated carcinoma, immunohistochemically consistent with a bronchial carcinoma. As intramedullary spinal cord metastases are generally associated with poor survival, a palliative irradiation of the levels C1-6 was additionally performed. Unfortunately tetraparesis and numbness remained. The very rare occurrence of intramedullary spinal cord metastasis and the absence of pathognomonic symptoms often lead to a delay until an underlying malignancy is discovered. Although rare, intramedullary spinal cord metastasis should be considered as a differential diagnosis of a spinal intramedullary lesion. Surgery and radiation are both options in the controversially discussed treatment of ISCM.

Background: Malignant gliomas in elderly patients are frequently under represented in neuro-oncology trials because of presumed low tolerability of gross-total resection and radiochemotherapy treatments. Thus, the balance of benefit versus adverse response of standard glioma therapy remains controversial. We hypothesized that older patients with malignant gliomas might also take advantage of extensive surgical procedures.

Patients and methods: We analyzed retrospectively 138 consecutive malignant glioma patients. Sixty-two patients were >65 years whereas seventy-six were

Results: At diagnosis, elderly patients showed a larger burden of comorbidities but they did not influence outcome significantly. Gross-total resection was associated with a longer survival as compared to biopsy and subtotal resection in both groups of elderly (P=0.05 and 0.001, respectively) and younger patients (P=0.004 and 0.003). Concerning complications, the only difference between both collectives was a higher incidence of psychosyndrome in the elderly group (P=0.016).

Conclusions: Our results indicate that gross-total resection of malignant gliomas in elderly patients is associated with a survival benefit without increased morbidity.

Spondylodiscitis is considered to be the main cause of epidural abscess. In this report, the authors present their concept for the management of the extended epidural abscess that occurs in combination with spondylodiscitis. It consists of debridement and fusion for spondylodiscitis together with epidural abscess drainage using a microscopically assisted percutaneous technique. In the period from April 2000 to April 2004, 5 patients with spondylodiscitis and an accompanying extended epidural abscess were operated on. The mean age of the patients was 66 years. There were 4 males and one female. The follow-up period ranged from 3-12 months. To manage the extended epidural abscess, the authors created one or two drainage sites along the extension of epidural abscess. These drainage sites were made using a microscopically assisted percutaneous approach. In all presented cases, the offending organism was Staphylococcus aureus. The postoperative infection markers showed marked regression. The postoperative control MRI demonstrated effective drainage of the extended epidural abscess. Regarding the neurological deficits, 3 patients previously classified as Frankel C showed an improvement to Frankel E within 3 months postoperatively. From these results, it seems that our technique (ventro-dorsal abscess drainage combined with a microscopically assisted percutaneous approach) could be a successful method for the management of the extended epidural abscess associated with spondylodiscitis.