Surgical treatment of unruptured intracranial aneurysms in a low-volume hospital--outcome and review of literature.

BACKGROUND: The aim of this study was to evaluate surgical outcome of unruptured intracranial aneurysms (UIAs) in a low-volume hospital and compare the results with the recent literature. METHODS: A retrospective review of all consecutive craniotomies for UIA from July 1999 through June 2009 was performed. Morbidity was defined as modified Rankin Scale (mRS) ≥ 3 and evaluated six weeks after surgery. Cognitive function was evaluated at rehabilitation-to-home discharge. A PubMed database search (2001-2011) seeking retrospective, single-center studies reporting on surgical outcome of UIAs was performed. RESULTS: There were 47 procedures performed in 42 patients to treat 50 UIAs (mean of 5 annual craniotomies). The mean age was 54.7 ± 12.1 years and mean aneurysm size was 7.6 ± 4.0mm. Favorable outcome (mRS 0-2) at six weeks after surgery was achieved in 45 of 47 procedures (95.7%). Aneurysm size ≥ 12 mm was statistically significant related to adverse outcome defined as mRS change ≥ 1 (71% vs. 29%; p = 0.018). Five patients (10.6%) with favorable neurological outcome (mRS 2) presented with cognitive impairment at rehabilitation-to-home discharge. There was no significant difference in overall morbidity and mortality comparing low- and high-volume hospitals (4.0% vs. 4.8%; p = 0.85). CONCLUSIONS: Low-volume hospitals may achieve good results for surgical treatment of UIAs. The results indicate that defining numeric operative volume thresholds is not feasible to guide centralization of aneurysm treatment.

[Adult syringomyelia - a syndrome of different origins]. / Die Adulte Syringomyelie - ein Krankheitsbild mit Verschiedenen Ursachen.

Syringomyelia describes an intra-medullary cyst in the spinal cord. In the adult patient, the pathology mostly results from Chiari-I-malformation or from severe spinal trauma. The clinical picture varies broadly, but symptoms often include pain and progressive neurologic deficits. During the clinical course, muscular atrophy and loss of pain and temperature sensation may develop in the affected region. Today, magnet resonance imaging helps to detect syringomyelia at an early stage. The interdisciplinary therapeutic approach includes an adequate pain treatment and physiotherapy, in selected cases a surgical intervention by an experienced surgeon. If not treated surgically, most symptomatic patients experience progressive neurologic deficits that may lead to severe paragplegia and chronic neuropathic pain.

[An uncommon reason for facial hypoesthesia]. / Eine ungewöhnliche Ursache für faziale Hypästhesie.

A 58-year-old female admitted herself to the emergency department with progressive left-sided facial hypoesthesia. Magnetic resonance imaging revealed a 20 mm-sized aneurysm of the left vertebral artery leading to compression of the trigeminal nerve. An endovascular occlusion with a combined coiling and flow-diverter was performed. The left posterior inferior cerebellar artery (PICA) arised from the aneurysmal sac. Despite an extensive infarction of the left PICA-territory, the patient convalesced well and presented completely independent and without symptoms at the 4-week follow-up.

[Aneurysmal subarachonid haemorrhage]. / Aneurysmatische Subarachnoidalblutung.

The most characteristic symptom of an aneurysmal subarachnoid haemorrhage (aSAH) is a sudden onset of severe headache, which can be accompanied by meningism, impaired consciousness, and vegetative symptoms. A cerebral CT scan is the initial diagnostic tool of choice if aSAH is suspected. The localisation and morphology of the aneurysm is depicted in a CT-angiography and/or conventional panangiography. Until definitive exclusion of the aneurysm by either microsurgical clipping or endovascular coiling, rebleeding should be avoided implicitly. The postoperative phase, especially in patients with severe aSAH is embossed with the occurrence of disease-specific complications (cerebral vasospasm, intracranial hypertension, seizure disorder, hydrocephalus) and consecutively increased risk for secondary brain injury. Furthermore, many patients present systemic complications such as electrolyte disturbances and cardiac dysfunctions. Early identification and therapy of cerebral and systemic complications are very important in order improve functional outcome.

[Trigeminal neuralgia - pathophysiology, clinical aspects and treatment]. / Trigeminusneuralgie - Pathophysiologie, klinische Aspekte und Therapie.

The trigeminal neuralgia is characterised by paroxysmal appearing fulgurous stabbing pain. Its medical condition is caused through a local-circumscribed demyelinisation of the trigeminal nerve with consecutive conduction of salting impulses on afferent pain fibres. It is essential to differentiate the symptomatic from the idiopathic trigeminal neuralgia. As primary management, a pharmacological treatment with anticonvulsants is recommended in order to attenuate the ectopic-generated pain impulses. Different neurosurgical procedures are available in cases of resistance to therapy. Thereby, causal surgery in form of microvascular decompression is not only the operative treatment of choice, but because of the excellent results also a fundamental support of the theory of vascular compression. A comprehensive knowledge about diagnosis and management of trigeminal neuralgia is essential to treat patients efficiently and successfully. This synopsis summarises the current recommendations concerning diagnostics and therapeutic options.

[Traumatic dissection of extra- and intradural arteries]. / Traumatische Dissektion extra- und intraduraler Arterien.

Dissection of extra- and intradural arteries is a common cause of cerebral insult in younger patients (<45 years). In patients with corresponding craniocervical injury and symptoms (carotidynie, ipsilateral headache, partial Horner syndrome, cranial nerve palsy) arterial dissection is always to be considered. Essential in diagnosing arterial dissection is the verification of the intramural hematoma and morphologic changes in the vessel (stenosis, pseudoaneurysm) by means of CT/CTA (acute phase) or MRI/MRA (subacute phase). These patients need to be monitored in an intensive care unit setting. The acute therapy includes anticoagulation or inhibition of thrombocyte aggregation. We present two cases with delayed cerebral infarction due to traumatic extra- and intradural arterial dissection after a motor vehicle accident. To perform primary diagnostic quickly and adequately may avoid permanent neurological deficit in these patients.