Transient tetraplegia and vegetative dysfunction depending on cervical positioning caused by a cervical spinal chordoma.

A 39-year-old man with acquired torticollis suffering from cervicobrachialgia and neurological deficits is presented. Due to a change in head position a transient reproducible tetraplegia and severe vegetative dysfunctions were caused. The origin of this uncommon serious combination of symptoms and signs was a chordoma of the upper cervical spine. After surgical decompression the patient was free of neurological deficit and pain. Review of the literature did not reveal any similar case.

Intracranial image-guided neurosurgery: experience with a new electromagnetic navigation system.

BACKGROUND: The aim of image-guided neurosurgery is to accurately project computed tomography (CT) or magnetic resonance imaging (MRI) data into the operative field for defining anatomical landmarks, pathological structures and tumour margins. To achieve this end, different image-guided and computer-assisted, so-called "neuronavigation" systems have been developed in order to offer the neurosurgeon precise spatial information. METHOD: The present study reports on the experience gained with a prototype of the NEN-NeuroGuard neuronavigation system (Nicolet Biomedical, Madison, WI, USA). It utilises a pulsed DC electromagnetic field for determining the location in space of surgical instruments to which miniaturised sensors are attached. The system was evaluated in respect to its usefulness, ease of integration into standard neurosurgical procedures, reliability and accuracy. FINDINGS: The NEN-system was used with success in 24 intracranial procedures for lesions including both gliomas and cerebral metastases. It allowed real-time display of surgical manoeuvres on pre-operative CT or MR images without a stereotactic frame or a robotic arm. The mean registration error associated with MRI was 1.3 mm (RMS error) and 1.5 mm (RMS error) with CT-data. The average intra-operative target-localising error was 3.2 mm (+/- 1.5 mm SD). Thus, the equipment was of great help in planning and performing skin incisions and craniotomies as well as in reaching deep-seated lesions with a minimum of trauma. INTERPRETATION: The NEN-NeuroGuard system is a very user-friendly and reliable tool for image-guided neurosurgery. It does not have the limitations of a conventional stereotactic frame. Due to its electromagnetic technology it avoids the "line-of-sight" problem often met by optical navigation systems since its sensors remain active even when situated deep inside the skull or hidden, for example, by drapes or by the surgical microscope.

Accurate placement of the distal end of a ventriculoatrial shunt catheter using Alphacard: direct intraoperative comparison with fluoroscopy.

BACKGROUND: Surgical insertion of a ventriculoatrial shunt requires accurate placement of the atrial catheter in the right atrium in order to prevent postoperative complications. Fluoroscopy is the standard method for monitoring correct positioning of the catheter. METHODS: This paper reports a prospective study in 50 patients with the aim of comparing electrocardiographic monitoring of the catheter position by means of Alphacard with concomitant intraoperative fluoroscopic examination. The Alphacard was evaluated in terms of accuracy, time requirement, and ease of handling. The mean postoperative follow-up period was 54 (range 42-66) months. FINDINGS: Reliable control of the catheter position was possible by means of electrocardiographic guidance in all 50 patients (100%) by fluoroscopy in 49 cases (98%). The average time required for intra-operative monitoring of the catheter position was 55 (40-70) seconds for electrocardiography as compared to 8 (5-12) minutes for fluoroscopy. None of the patients showed obstruction of the atrial catheter during the postoperative follow-up period. INTERPRETATION: Alphacard offers an excellent alternative for monitoring the position of the tip of an atrial catheter because it requires little equipment and time. In terms of reliability, it is comparable or even superior to fluoroscopy.

Adult neuronal ceroid lipofuscinosis with clinical findings consistent with a butterfly glioma. Case report.

The authors report a case of neuronal ceroid lipofuscinosis (Kufs' disease) confirmed by stereotactically obtained brain biopsy findings and initially diagnosed as a butterfly glioma. The presenting symptoms in the 64-year-old patient were mental alterations with progressive dementia, followed by muscular atrophy and myoclonia with distal preponderance. The mild initial disturbances of coordination increased, and the patient developed a markedly ataxic gait. Computerized tomography (CT) scanning and magnetic resonance imaging revealed generalized cerebral atrophy and a bifrontal space-occupying lesion involving the callosum. The original "clearcut" diagnosis of glioblastoma multiforme, based on CT scans, was unexpectedly disproved by examination of stereotactically obtained brain biopsy specimens, which revealed a neuronal ceroid lipofuscinosis (Kufs' disease). To the authors' knowledge, this is the first report of a case presenting with both diffuse brain atrophy and localized accumulation of neuronal lipofuscin, mimicking a mass lesion on radiological studies.

[Indications for surgical therapy of aneurysmic subarachnoid hemorrhage--current status]. / Indikationsstellung zur operativen Therapie der aneurysmatischen Subarachnoidalblutung--Aktueller Stand.

The most common cause of spontaneous subarachnoid bleeding (SAB) is a freshly ruptured cerebral aneurysm. The prognosis of an aneurysmal SAB essentially depends on the extent of the bleeding, the sequelae of subsequent vasospasms and the increase in intracranial pressure. Effective measures, such as increasing systemic blood pressure, can only be taken if the aneurysm is eliminated as quickly as possible. However, there are situations in which waiting is indicated. Clipping a cerebral aneurysm is a demanding operation, which requires a high degree of concentration and competence from the entire surgical team. A review of the literature (1990-1996) and a survey of 10 German and 10 international cerebrovascular centers yielded the following update of indications and contraindications for the surgical management of aneurysmal SAB: There is an absolute contraindication for aneurysm clipping in patients over 80 years of age in stage V according to Hunt and Hess and in poor general condition. There is a relative contraindication in patients over 90 years of age no matter what the stage according to Hunt and Hess is, as well as in those over 70 years in stage V according to Hunt and Hess and in poor general condition. Different opinions have been expressed for patients over 70 years in stage V according to Hunt and Hess. The surgical indication is controversial in patients with vasospasm detected by Doppler ultrasonography or by angiography. Emergency aneurysm clipping is performed in the presence of a space-occupying intracranial hematoma. Otherwise, emergency aneurysm elimination is not performed at night in any of the hospitals surveyed, but both angiography and surgery are carried out the next morning in the majority of hospitals. A tired neurosurgeon or surgical team operating at night may constitute a greater risk for the patient than rebleeding. For legal reasons, this aspect was discussed and accepted as another relative contraindication in the annual meeting of the German Neurosurgical Society in Hamburg in 1996.