Treatment strategies of space-occupying intradural metastases of the cauda equina of nonneurogenic origin.

BACKGROUND: Compressive intradural metastases of the cauda equina are a rare site of metastatic spread in systemic cancer. So far, only few reports have been published with conflicting statements concerning a surgical versus nonsurgical approach. METHOD: Five patients with symptomatic space-occupying intradural metastases of the cauda equina were analyzed retrospectively, focusing on the influence of surgical intervention on pain relief, neurological outcome and thus the patients' quality of life. FINDINGS: At the time of diagnosis, all patients were in an advanced metastatic state. Surgical resection was the primary treatment in four patients and radiotherapy in one. Despite infiltration of the cauda rootlets, gross total tumour resection could be achieved in two of the four patients treated surgically. Functional outcome was beneficial in these patients with marked and immediate relief of pain and improvement of motor function even following incomplete tumour resection. CONCLUSIONS: Surgical treatment of compressive intradural metastases of the cauda equina seems to be feasible with low operative risk and with the potential benefit of an immediate relief of pain and improvement in motor function and thus an increase in quality of life.

Severe inflammatory reaction of the optic system after endovascular treatment of a supraophthalmic aneurysm with bioactive coils.

We report on a patient who, after a symptom-free interval, developed severe vision impairment and whose MR imaging demonstrated extensive edema in the central nervous tissue neighboring the treated aneurysm. To our knowledge, this is an unreported complication of endovascular treatment of aneurysms.

Incidence and outcome of traumatic brain injury in an urban area in Western Europe over 10 years.

INTRODUCTION: Valid epidemiological data on incidence and outcome of traumatic brain injury (TBI) show great variability. A study on incidence, severity and outcome of TBI was conducted in an urban area of one million inhabitants. MATERIALS AND METHODS: 130,000 prehospital emergencies were screened for TBI. INCLUSION CRITERIA: Glasgow Coma Scale (GCS) score or=2 with confirmed TBI via appropriate diagnostics. RESULTS: Annual incidence was 7.3/100,000. Overall mortality rate was 45.8%: 182 (28%) were prehospital deaths, 116 (17.8%) patients died in hospital. Two hundred and fourteen of 352 (60.8%) surviving patients were sufficiently rehabilitated at discharge [Glasgow Outcome Scale (GOS) score = 1], but 138 patients (39.2%) survived with persisting deficits. GOS was associated with initial GCS and AIS(head). CONCLUSION: The incidence of TBI was lower compared to the literature. The overall mortality was high, especially prehospital and early in-hospital mortality rates.

The incidence and outcome of severe brain trauma - Design and first results of an epidemiological study in an urban area.

Epidemiological data on the incidence, the prehospital and hospital care and the outcome of traumatic brain injury in Germany are scarce. It is therefore difficult to estimate the importance of this injury with respect to magnitude as well as effectiveness and efficiency of therapeutic concepts. We therefore planned a study that was supposed to provide population based epidemiological data in the field of severe brain trauma from the site of the accident until discharge from hospital.All 90.000 prehospital emergencies that were cared for by emergency physicians in Cologne from January 1990 until December 1996 were screened for identification of severe brain trauma. Their clinical course was reviewed using standard records and patients were included if they had their accident within the city of Cologne and fullfilled the final inclusion criteria of GCS ≤ 8 or AISHead ≥ 3. 650 eligible patients were identified of whom 530 had complete datasets (follow-up 80 %). Univariate statistical analysis was performed for all relevant variables. The main study endpoints were incidence and outcome of severe brain trauma.The annual incidence of severe brain trauma in Cologne (1 mio. inhabitants) was 93. The average age was 39 years and 71 % of the patients were male. The average prehospital GCS was 6.8, the average prehospital Trauma Score was 8.3 points. 49 % of the study population suffered from multiple injuries. The overall mortality rate was 46,6 %. 60 % of deaths occurred within the prehospital setting.The incidence of severe brain trauma in Cologne in this study was significantly lower compared to what could be expected from the literature. The overall mortality was high, especially the high prehospital death rate is striking.

Brainstem auditory evoked potentials in syndromes of decerebration, the bulbar syndrome and in central death.

The results are reported of serial brainstem auditory evoked potentials recordings in 51 patients with decerebration and bulbar syndrome. In contrast to the stability of latencies of single components of the potential in healthy subjects, patients with decerebration syndromes show considerable instability and an increase in the latency of all the components of the potential. In 34 decerebrate patients the P-I latency and the interpeak latencies for the medullo-pontine and ponto-mesencephalic segments as well as the central conduction time were significantly increased. There was marked reduction of the amplitude of P-V and P-III and deformation of the single components of the potential with widening and smoothing. The amplitude ratios A-V to A-I and A-III to A-I were significantly decreased. The findings are interpreted as due to mesencephalic and pontine functional disturbance during decerebration. The brainstem auditory evoked potential can be used to estimate the time of brain death. Possible causes of misinterpretation are discussed.

Herniation of an intervertebral disc with cauda compression syndrome in childhood.

A case of a lumbosacral disc herniation of traumatic origin with compression of the cauda equina in a child is reported. The problems of early diagnosis, timely operative procedure, and prognosis of neurological deficit of operated disc herniation in childhood are discussed.

Age related signal decrease in functional magnetic resonance imaging during motor stimulation in humans.

Right handed healthy volunteers underwent functional magnetic resonance imaging (fMRI) examinations on a 1.5 Tesla MRI-scanner (Gyroscan ACS NT; Philips, Best, NL). Blood oxygen level dependent (BOLD) images were obtained using a three dimensional multi-shot echo planar imaging sequence employing a shifted echo technique (Principles of echo shifting with a train of observations). Finger tapping of the right hand was used as a task for motor stimulation. A total of 86 subjects was included into statistical analysis. Absolute and relative signal differences and cluster sizes of activation for the left motor cortex were obtained. In addition, Z-score, pooled Z-score and cross correlation activation maps were calculated and matched with high resolution anatomic images. A significant decrease with age could be detected for absolute and relative signal intensity differences for the whole group and for the male subgroup. Correlation analysis for the female subgroup also bore negative albeit non-significant correlation coefficients. An age-related decline of BOLD-contrast can be assumed to explain signal decrease. This age-related effect should be considered in clinical fMRI applications.

Multiple interstitial substances measured by microdialysis in patients with subarachnoid hemorrhage.

OBJECTIVE: Intracerebral microdialysis is a tool to monitor metabolic disturbances in the brains of patients with severe head injuries or subarachnoid hemorrhage (SAH). In the search for putative indicators of primary and secondary brain damage, we measured multiple metabolites in the dialysates of patients with SAH, to elucidate their significance for the outcomes of the patients as well as their temporal profiles of liberation after the insult. METHODS: Microdialysis probes were placed, with a ventriculostomy catheter for drainage of cerebrospinal fluid, into a frontal lobe of 10 patients with aneurysmal SAH, for 4.6 +/- 0.5 days. Amino acids, metabolites of glycolysis, purines, catecholamines, and nitric oxide oxidation byproducts were measured by high-performance liquid chromatography. Spearman's correlation coefficient and Student's t test were used to compare the levels of the metabolites with the outcomes of the patients, as assessed using the Glasgow Outcome Scale, 3 months after the ictus. RESULTS: For patients with unfavorable outcomes (Glasgow Outcome Scale scores of 1-3), which were primarily associated with the development of large infarctions, dialysate levels of excitatory amino acids increased up to 30-fold, those of lactate up to 10-fold, and those of nitrite up to 5-fold, compared with normal levels observed for patients with favorable outcomes (Glasgow Outcome Scale scores of 4 or 5). When average peak concentrations in the dialysates of patients with favorable and unfavorable outcomes were compared, significantly higher levels of excitatory amino acids, taurine, lactate, and nitrite, but not of purines and catecholamines, were observed for those with poor outcomes (P < 0.05). With respect to the temporal profiles of the average metabolite concentrations, the significantly increased levels of amino acids observed for patients with poor outcomes followed a biphasic course, with maximal concentrations on the first and second days or the seventh day after the insult (P < 0.01). CONCLUSION: These data confirm the usefulness of excitatory amino acids and lactate as major parameters for neurochemical monitoring for patients threatened by acute cerebral disorders. Other substances, such as taurine and nitrite, were also demonstrated to be potentially predictive. Release of these substances into the extracellular fluid of the brain might be particularly relevant for the development of secondary brain damage after SAH, e.g., infarction or brain swelling.

Recording nasal muscle F waves and electromyographic activity of the facial muscles: a comparison of two methods used for intraoperative monitoring of facial nerve function.

OBJECT: A comparison of two electrophysiological methods used to assess facial nerve function intraoperatively was conducted in 33 patients with tumors of the cerebellopontine angle. METHODS: All 33 patients had presented with normal facial nerve function preoperatively. After general anesthesia had been induced by a mixture of midazolam and fentanyl, continual online EMG recordings from the orbicularis oculi and oris muscles were alternated with nasal muscle F-wave recordings. Facial nerve outcomes, assessed using a modified House-Brackmann scale, varied among good (48%), moderate (18%), and poor (33%). Analysis of electromyographic (EMG) data resulted in a significant correlation between the finding of only transient manipulation-evoked activity and a good outcome, whereas in cases in which there was poor outcome, an increase in the amplitude or duration of ongoing activity was detected. A permanent loss of nasal muscle F waves specifically appeared to indicate a severe dysfunction of the facial nerve that was linked to a poor outcome. All patients with latency and/or amplitude changes or even a transient loss of the F wave achieved good or moderate facial nerve outcomes. A transient loss of the F wave, however, was detected significantly more frequently in patients with moderate outcomes. None of these patients exhibited normal facial function (House-Brackmann Grade I) postoperatively. CONCLUSIONS: Online EMG monitoring can provide some information on imminent or even present damage to the facial nerve intraoperatively. The diagnostic sensitivity, specificity, and positive predictive values of a permanent F-wave loss, however, are much higher than those of EMG monitoring. Additionally, this loss of the F wave is supposed to be transient if the surgical procedure is stopped until the F wave recovers. Therefore, F-wave monitoring serves to alert the surgeon that the facial nerve is about to receive a lesion.

Growth rate of incidental meningiomas.

A meningioma was incidentally identified with computerized tomography (CT) in 17 patients without relevant clinical signs. The tumor was not removed, but biopsy confirming a meningioma was obtained from one patient. Tumor growth rate was calculated from repeat CT scans or follow-up magnetic resonance imaging. The annual growth rate ranged from less than 1% to 21%. It is concluded that in nonsymptomatic meningiomas with a low growth rate a nonsurgical approach may be warranted.

Insulin-like growth factor binding protein-3 levels during early and late follow-up after surgery in acromegalic patients.

Disease activity in acromegaly is accurately reflected by growth hormone (GH) concentration during oral glucose tolerance test (OGTT) and insulin-like growth factor-I (IGF-I) levels, representing an integrated index of GH activity. This prospective study was performed to evaluate whether plasma IGF binding protein 3 (IGFBP-3) might also reflect the hormonal disease activity in pituitary acromegaly after operative treatment during early and late follow-up. Twenty-two acromegalic patients were studied. Data were obtained pre-, intra- and post-operatively in 13 cases. In 9 patients the acromegalic activity was studied only after treatment. The hormonal assessment included repeated blood samples for estimation of IGF-I, IGFBP-3 and repeated OGTTs. In each case 100 sigma g octreotide (Sandostatin lambda, Sandoz, Basel) was injected to test the acute response of GH, IGF-I and IGFBP-3. Intraoperatively, GH levels were estimated to examine acutely the influence of tumour reduction on GH levels. Patients were considered cured when GH levels (GH60min) were less than 2 ng/ml during OGTT 4 weeks after surgery. The data outlined that in patients with normalized GH60min levels, normalized IGFBP-3 levels were noticed 4 weeks and 12 months post-operatively. In non-cured patients normalized IGFBP-3 concentrations were found in 11 out of 15 cases in the late post-treatment phase. In contrast only 1 of 7 cured patients had persistently elevated IGF-I levels within the first month post-operatively, whereas no case of the non-cured patients had IGF-I values in the normal range. Despite these observations a strong correlation of IGF-I and IGFBP-3 did not exist before one year post-operatively -- either in the cured or in the non-cured patients. Serum IGFBP-3 in patients with pituitary acromegaly does not provide a predictive value of appreciable magnitude concerning cure or non-cure from the disease- whether examined early or late in the post-operative period. Absolute levels of IGFBP-3 may thus cause misinterpretation concerning cure of acromegalics after surgery.

Functional magnetic resonance imaging of human pontine auditory pathway.

The purpose of this study is to visualize brainstem auditory pathways by functional magnetic resonance imaging (fMRI). Eighteen healthy volunteers (age 28 to 42 years) with normal hearing function underwent fMRI examination on a 1.5 Tesla imaging system (Philips, Best, The Netherlands) with periodic click stimulation. Blood oxygen level dependent images were obtained using a three-dimensional EPI sequence with shifted echo technique (principles of echo shifting with a train of observations). Control scans without click stimulation were obtained in the identical setting. Cross correlation activation maps were calculated using a postprocessing tool (Philips). They were matched with anatomic slices of identical orientation and thickness. Five of 18 subjects were excluded because of motion artifacts. In 4/13 significant activation was observed at the root entry zone of the ipsilateral acoustic nerve corresponding to the cochlear nuclei. In 11/13 subjects, significant activation was found in the same slice contralaterally close to the floor of the 4th ventricle, corresponding to the expected region of the superior olivary nucleus. Activation of the rostral parts of the auditory pathway (inferior colliculus, medial geniculate body) was not found. In the absence of the stimulus no activation occurred in these structures. It was concluded that activation of the brainstem auditory pathways by click stimuli can be visualized by fMRI.

Acute nontraumatic spinal epidural hematomas. An important differential diagnosis in spinal emergencies.

STUDY DESIGN: The clinical data of five patients with spontaneous spinal epidural hematoma (SSEH) were reviewed. OBJECTIVES: To assess the clinical outcome of patients with SSEH after surgical decompression. SUMMARY OF BACKGROUND DATA: The outcome in SSEH is essentially determined by the timing of the operation. Therefore, early and precise diagnosis is necessary. METHODS: A retrospective analysis of five patients with SSEH was performed. The clinical data were stratified according to the Frankel Score. Special interest was given to the relevance of rapid and exact diagnosis and immediate therapeutic intervention. RESULTS: Diagnosis of SSEH was established preoperatively by means of computed tomography (one case) or magnetic resonance imaging (three patients) and intraoperatively in one case. Lumbar myelography had been false negative in one patient, computed tomography false-negative in two patients. Surgical decompression was performed in four patients within 24 hours after the onset of symptoms. Favorable postoperative functional results were found only in one patient whose symptoms had been present for less than 12 hours and in the case of an incomplete cauda equina syndrome. CONCLUSIONS: The results of the current series demonstrate both the superiority of magnetic resonance imaging for diagnosis of SSEH as well as the necessity of early decompressive surgery in cases of sensorimotor paralysis after SSEH.

Does wave VI of BAEP pertain to the prognosis of coma?

OBJECTIVES: The significance of brainstem auditory evoked potential (BAEP) wave VI for the outcome of comatose patients was assessed and compared to the prognostic impact of median nerve evoked somatosensory potential (MSEP) recording. PATIENTS AND METHODS: One hundred sixteen patients in a comatose state due to traumatic brain injury (n = 57) and to intracerebral hemorrhage or tumours (n = 59) were investigated prospectively. Outcome was assessed 3 months after the onset of coma using Glasgow Outcome Score (GOS). Standard BAEP and MSEP recordings were obtained within 24 h after coma onset. The frequency of findings was correlated with outcome by means of non-parametric statistical analysis. Additionally, 27 healthy volunteers were studied to confirm the constant presence of wave VI in normal BAEP. RESULTS: In healthy controls, wave VI was present in 53/54 ears stimulated. Outcome correlation analysis revealed a significantly (p < 0.01) higher frequency of abnormal wave VI in patients with unfavourable outcome (GOS 1-3) irrespective of the underlying pathology. Similarly, abnormal MSEP findings were significantly more frequent in this outcome group. Diagnostic sensitivity for an unfavourable outcome was low for both parameters, whereas specificity and positive predictive value of abnormal wave VI as well as of abnormal MSEP were equally high. CONCLUSION: Abnormal BAEP wave VI bears prognostic information in comatose patients.

[The sacral perineural system--are there radiological criteria for an indication for surgery? First results and literature survey]. / Sakrale Perineuralzysten--gibt es radiologische Kriterien für eine Operationsindikation? Eigene Ergebnisse und Literaturübersicht.

PURPOSE: To establish recommendations for diagnostic imaging of cystic lesions of the sacral region and to evaluate for potential predictors of therapeutic outcome. METHODS: Conventional imaging of the lumbar spine, conventional CT, myelography, post myelo-CT and MRI were performed in 7 symptomatic [corrected] patients. All patients underwent operative decompression and histological examination. The radiographic examinations were reevaluated retrospectively and correlated with the postoperative outcome. RESULTS: In one patient the differential diagnosis of a neurinoma could not be excluded with CT and CT-myelography alone. In all 7 patients MRI provided a definite diagnosis and a precise presentation of the cyst extension. A complete postoperative remission of symptoms was noticed in 4, a partial remission in three cases. The correlation of cyst extension, cyst shape, and the communication with the subarachnoid space did not provide predictive information concerning operative outcome. CONCLUSION: MR can be used as the sole imaging tool for demonstration of cystic lesions. Relevant disadvantages in comparison to myelography and myelo-CT were not evident. No imaging modality could predict the value of surgical intervention.

Chronic subdural hematoma: surgical treatment and outcome in 104 patients.

BACKGROUND: The common occurrence of chronic subdural hematoma (CSDH) in older patients raises some diagnostic and therapeutic difficulties. Despite general agreement about the indication of operation, the extent of surgery is still discussed controversially. We have, therefore, reviewed operative findings and outcome in 104 patients with CSDH. METHODS: Retrospective analysis was performed by differentiating age < or = 60 years (n = 28) versus age > 60 years (n = 76) and burr hole craniostomy with a size range from 12-30 mm (n = 94) versus larger craniotomy (n = 10). All patients received closed-system drainage of the subdural space for 2-4 days. RESULTS: Four patients older than 60 years died within 30 days after surgery, two in each operative group. Excluding these postoperative deaths, 17 out of 92 patients (18.5%) after burr hole trepanation and one out of eight patients (12.5%) after craniotomy required reoperation due to rebleeding (n = 6), residual subdural fluid (n = 4), and residual thick hematoma membranes (n = 8). Eight patients, who had been initially treated by burr hole craniostomy despite preoperative detection of neomembranes by contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI), recovered without further intervention. Clinical outcome was good in both operative groups. The percentage of patients without or with only mild neurologic deficits at the time of discharge from the hospital was 72.3% in the burr hole and 70.0% in the craniotomy group, respectively. CONCLUSIONS: The clinical data of the present study suggest that burr hole craniostomy with closed-system drainage should be the method of choice for the initial treatment of CSDH, even in cases with preoperative detection of neomembranes. Craniotomy should be carried out only in patients with reaccumulating hematoma or residual hematoma membranes, which prevent reexpansion of the brain.

Functional and psychosocial outcome one year after severe traumatic brain injury and early-onset rehabilitation therapy.

This study evaluates the impact of early-onset continuous rehabilitation treatment on the 1-year outcome of patients after severe traumatic brain injury. Immediately after recovery from mechanical ventilation, a total of 48 patients underwent a complex early rehabilitation treatment until they were discharged from hospital and local ambulant care was deemed sufficient. The follow-up examination took place 12 months after trauma. Data reveal that at 1 year 91.6% of the patients were completely or restrictedly independent of care and capable of carrying out activities of daily living, although they frequently were still suffering from marked behavioural and also from certain sensorimotor deficits. Only 45.8% of the patients were obviously able to work without restrictions or had returned to work. In those subjects who were not or only very restrictedly able to work, behavioural and speech deficits were significantly more frequent. Behavioural and speech deficits seem to represent the major cause that hinders professional reintegration. Rehabilitation therapy therefore should be specifically directed to improve these deficits.

Clinical relevance of somatostatin receptor scintigraphy in patients with skull base tumours.

The differential diagnosis of tumours in the skull base is often difficult. With the experience that various intracranial tumours differ in their expression of somatostatin binding sites (SBS) somatostatin receptor scintigraphy (SRS) with the somatostatin analogue octreotide can give additional information of the tumour entity. Seventy patients with various tumours of the skull base were examined with 111Indium-labelled DTPA-octreotide injected i.v.. Planar and tomographic images were obtained with a gamma camera 4-6 and 24 hours after injection. All of the meningiomas (unifocal and multifocal tumours in various locations) showed a high density of SBS whereas in none of the examined neurinomas SR were found. Pituitary adenomas revealed in only 50% SR in different concentrations and independent of the endocrine activity. SRS can help in the differential diagnosis between meningiomas and other tumours, postoperative scar or radionecrosis at the skull base. A dural infiltration with meningioma tissue ("meningeal sign") may be discriminated from a reactive hypervascularisation in lesions with a diameter > 0.5 cm. We conclude that SRS can offer additional diagnostic aspects in the pre- and postoperative management of patients with skull base tumours.

Rehabilitation of hearing and communication functions in patients with NF2.

Most patients with neurofibromatosis type 2 (NF2) lose hearing either spontaneously or after removal of their neurofibromas. The patient may benefit from conventional hearing aids if, due to modern microsurgery and intraoperative monitoring the integrity of the cochlea and the 8th nerve is preserved. With lost auditory function but preserved electrical stimulibility of the 8th nerve a cochlear implant may be appropriate. But if the patients have no remaining 8th nerve to stimulate, there is no benefit from cochlear implants. Until some years ago, vibrotactile aids, lip-reading, and sign language have been the only communication modes available to these patients. With auditory brain stem implants it is now possible to bypass both the cochlea and the 8th nerve and to stimulate the cochlear nucleus directly. Stimulation of the devices produces useful auditory sensations in almost all patients. Testing of perceptual performance indicated significant benefit from the device for communication purposes, including sound-only sentence recognition scores and the ability to converse on the telephone. Also lip-reading is significantly improved with brain stem implants. The successful work of an auditory brainstem program center depends very much on the close interdisciplinary collaboration between the Departments of Neurosurgery and ENT-surgery. In the future new developments like speech processing strategies and new designed electrodes accessing the complex tonotopic organization of the cochlear nucleus may further improve rehabilitation in these patients who would have been deaf some years ago.

Early rehabilitative concepts in therapy of the comatose brain injured patients.

OBJECTIVES: To evaluate the changes of vegetative parameters and behavioural assessment in comatose patients after severe brain injury during the Multimodal-Early-Onset-Stimulation (MEOS) in early rehabilitation. MATERIAL AND METHODS: We studied 16 predominantly male (3:1) patients, age mean 43.6 (16-77) years. Mean coma duration was 22.2 (8-41) days, therapy duration (MEOS) 9.8 (1-30) days. The initial GCS was 6.6 (3-9), KRS 5.3 (0-15). Including criteria for therapy: Severe head trauma, coma for at least 48 hours (GCS < 8), vegetative stability, normal intracranial pressure, abandon of mechanical ventilation, sedation and severe infections. MEOS was finished in achieving GCS > 9, follow-up investigations were made after 2 years. RESULTS: We identified significant changes in two vegetative parameters (heart/respiratory frequencies), even in deep coma (GCS 3-4). Most significant changes were caused by tactile and acoustic stimulation. Standardized behavioural assessment turned out to be particularly advisable in cases of medium coma (GCS 5-7). Stimulation of tactile and acoustic senses resulted mainly in mimical, head and eye movements. Follow-up was possible in 14 patients: One remained in a vegetative state (GOS 2), two exhibited severe neurologic/neuropsychologic deficits, depending on care (GOS 3), six substained major functional deficits (GOS 4), at though they were able to perform the tasks of daily life on their own, three patients reached GOS 5. Two returned to their former jobs. DISCUSSION AND CONCLUSION: The present results indicate that stimulation therapy should be based on a close observation of patterns of behaviour, and, at least in deep coma stages, involve the registration of vegetative parameters. It may be sensitive to identify parameters predicting a favourable or unfavourable outcome. Preliminary data seem to support the hypothesis that the absence of any response to external stimuli is indicative of an unfavourable outcome.