Primary optic nerve sheath meningiomas: a follow-up study.

OBJECTIVE: The management of optic nerve sheath meningiomas (ONSM) remains controversial, but includes surgery, radiotherapy and plain observation. We present a follow-up study and treatment modalities based on our classification system. PATIENTS AND METHODS: A retrospective analysis was performed of 90 patients with optic nerve sheath meningiomas who were treated between 1991 and 2008 (n=65 surgery only, n=5 radiation only, n=18 surgery and postoperative radiation, n=2 observation). Follow-up data was available, ranging from 6 to 220 months with a median of 45.8 months. RESULTS: Our classification system differentiates between intraorbital (type 1), intracanalicular or intrafissural (type 2), and intraorbital and intracranial (type 3) ONSMs. Thirty-seven tumors demonstrated extension through the optic canal (type 2a). 41 further tumors reached the chiasm (type 3a) or contralateral side (type 3b). Visual acuity was not significantly influenced by surgery but did become worse with a longer duration of preoperative symptoms and a longer follow-up period. Radiotherapy improved vision in 4 and preserved vision in 16 out of 23 cases. CONCLUSIONS: Loss of vision in optic nerve sheath meningiomas is a question of time. Radiotherapy should be offered for intraorbital ONSM. Surgery with decompression of the optic canal and intracranial tumor resection is still favored for tumors with intracanalicular and intracranial extension.

Management of orbital metastases.

True metastatic disease to the orbit is rare. We present an overview of the treatment and clinical outcome of 11 orbital metastases, carried out in our center from 1995 to 2002. The surgical approach was determined by the location and type of the lesion. The most common primary cancers that metastasized to the orbit were lung cancer, and breast cancer. In 6 patients, there was no history of cancer and in 1 patient the primary site remained obscure despite systemic evaluation. Three patients showed recurrent tumor growth despite chemo- and/or radiotherapy. The mean survival time was 15 months after diagnosis of orbital metastases. The systemic prognosis is generally poor. A multidisciplinary treatment is required. Therapeutic options include surgical biopsy, debulking or excision, hormonal therapy, chemotherapy, and radiation therapy.

Surgical management of tuberculum sellae meningiomas: involvement of the optic canal and visual outcome.

OBJECTIVE: To present a large series of surgically treated tuberculum sellae meningiomas with particular regard to involvement of the optic canal and visual outcome. METHODS: A retrospective analysis was done on 53 patients (40 female) with meningiomas originating from the tuberculum sellae who underwent surgery between 1991 and 2002. The standard surgical approach consisted of pterional craniotomy. Sixteen meningiomas extended posteriorly onto the diaphragma sella, 29 anteriorly to the planum sphenoidale, and 19 to the anterior clinoid process. Thirty seven tumours involved the optic canal, three bilaterally. Follow up ranged from 6 to 108 months (mean 29.9 months). RESULTS: Total macroscopic resection was achieved in 48 patients. Median tumour size was 2.6 cm. Postoperatively, visual acuity improved in 20 patients and deteriorated in seven. Preoperative and postoperative visual acuity worsened with increasing duration of preoperative symptoms and with increasing age. Extension into the intraconal space was a negative predictor. However, tumour size did not influence visual acuity. Recurrence occurred in two cases (21 and 69 months postoperatively). Two patients died from causes unrelated to the tumour. CONCLUSIONS: In the majority of patients with tuberculum sellae meningiomas, total resection may be achieved through a pterional approach with minimal complications.

Decompression of endocrine orbitopathy via an extended extradural pterional approach.

BACKGROUND: Numerous surgical decompression techniques have been described in endocrine orbitopathy. We present an overview of the treatment and clinical outcome of 13 patients with endocrine ophthalmopathy and 20 orbital decompressions via an extradural pterional approach, carried out in our center from 1995 to 2002. METHOD: Decompression of the antero- and posterolateral wall, of the roof, and the superior orbital fissure was performed in all cases. FINDINGS: Surgery reduced the degree of exophthalmos in all patients, and improved eye mobility and diplopia. Proptosis reduction at 3 months after surgery averaged 4.75 mm. A mean of 0.29 of better visual acuity was also achieved. There was no loss of visual acuity. Intra-ocular tension was reduced by 9.05 mm Hg on average. No diplopia was induced. INTERPRETATION: The pterional approach facilitates adequate proptosis reduction without inducing any double vision and allows adequate decompression of the orbital apex, and of the superior orbital fissure. This technique represents an effective and low-risk alternative to other techniques.

Neurosurgical management of orbital inflammations and infections.

BACKGROUND: We present an overview of the treatment and clinical outcome of 22 orbital inflammations and infections, carried out in our center from 1991 to 2002. METHOD: The surgical approach was determined by the location, and type of the lesion. Lateral orbitotomy was performed in 2 laterally located lesions, a transconjunctival approach in 8 medial, basal, extra-, intraconal lesions. Pterional intradural (5), and extradural (3) approaches were used in case of intracranial involvement or location in the orbital apex and optic canal. Lesions of the lid were operated via eyebrow incision. FINDINGS: Bacterial infections were confirmed in 5 cases (1 mucocele, 3 abscesses, 1 necrotizing inflammation). 15 patients were diagnosed as chronic inflammatory pseudotumors, 6 of whom showed a granulomatous subtype, and 3 involvement of the optic nerve. All patients failed to reveal systemic disease and had a localized orbital inflammatory process. 7 of the patients responded rapidly to systemic corticosteroid treatment with no episodes of recurrence. 3 patients showed recurrence despite corticosteroids. CONCLUSIONS: Orbital infections are cured by antibiotic treatment. The course of inflammatory pseudotumor is variable and requires multidisciplinary treatment. Therapeutic options include surgical biopsy or debulking, corticosteroids, chemotherapy, and radiation therapy.

Treatment and outcome of spinal dural arteriovenous fistulas.

Spinal dural arteriovenous fistula (dAVFs) are rare and often misdiagnosed entities. The choice between surgical treatment and embolization remains a matter of debate. We report on the cases of 18 patients (16 men, 2 women) with dAVF, who were treated surgically over an 11-year period. Patient age ranged from 32 to 84 years (mean 60 years). Six patients underwent embolization preoperatively. In three cases, angiography examinations failed to show feeding arteries on first examination at neuroradiological centers. Feeding arteries were at a different level than the fistula point in seven patients, two of them presenting with new anastomoses after embolization. Location of the fistula was midthoracic to lumbar. Seven patients were variously misdiagnosed with tumor, polyneuropathy, Guillain-Barré syndrome, syringomyelia, and knee disease. Clinical history was characterized by slowly progressive and fluctuating deterioration. Initial symptoms were mainly sensory loss and motor weakness, lasting for between 4 and 45 months before diagnosis (mean 15 months). Recurrent fistula after operation was found in one patient. In another patient, control angiography revealed a fistula at another level, and in a third, a fistula on the contralateral side. All three patients underwent reoperation. Temporary clinical deterioration was found in four patients, seven remained unchanged, and seven improved postoperatively. An attempt at embolization should be made following diagnostic angiography. Otherwise, surgery is our recommended treatment for spinal dural fistulas, as it has a lower failure rate. Because of the progressive natural course with severe deficits, we favor an early definitive treatment.

Treatment of orbital schwannomas and neurofibromas.

We present an overview of the treatment and clinical outcome of five orbital peripheral nerve tumours, carried out in our centre from 1999 to 2003. The surgical approach was determined by the location and extension of the lesion. Supraorbital orbitotomy was performed in two superiorly located lesions, a transconjunctival approach in one medial, basal, extraconal lesion. A pterional extradural approach was used in two cases with involvement of the apex, superior orbital fissure and cavernous sinus. Three patients were diagnosed as having schwannoma, one as neurofibroma, and one as cystic mixed neurofibroma and schwannoma. One patient suffered from multiple schwannomas [bilateral acoustic schwannomas, cervical schwannomas (NF2)]. One patient showed bilateral orbital neurofibromas, plexiform cutaneous neurofibroma (NF1) and glaucoma due to a coexisting Marfan's syndrome. Local recurrences were not seen after complete resection in all patients. Surgery is the therapeutic goal.

Complications of burr-hole craniostomy and closed-system drainage for chronic subdural hematomas: a retrospective analysis of 376 patients.

OBJECTIVE: Burr-hole craniostomy with closed-system drainage (BCD) is the most frequently used neurosurgical treatment of chronic subdural hematomas (cSDH). The surgical and medical complications of BCD have seldom been investigated systematically. The objective of this study was to define the frequency of surgical and medical complications following BCD for cSDH. METHODS: The medical records of 376 patients managed by BCD were reviewed with respect to complications during the hospital stay. RESULTS: Seventy-seven surgical complications (20.5%) were encountered. The most frequent minor complication after surgery was seizures (n 51, 13.6%). The most frequent major surgical complications were intracerebral hemorrhage and subdural empyema (n 8, 2.1% each). Four patients with intracerebral hemorrhage died, accounting for a surgical mortality rate of 1.1%. Fifty-nine medical complications (15.7%) occurred during the hospital stay. Pneumonia was the most frequent medical complication (n 29, 7.7%). Medical complications were fatal in 24 patients, accounting for a mortality rate of 6.4%. In 22 patients (5.8%), death was not related to a complication, but to the initial brain damage. The overall mortality rate was 13.3%. CONCLUSION: The rate of complications in patients with cSDH who underwent the BCD is high. The clinical relevance of medical complications has to be emphasized because of their substantial contribution to overall mortality.

Ocular manifestations of sphenoid mucoceles: clinical features and neurosurgical management of three cases and review of the literature.

BACKGROUND: Sphenoid mucoceles (SMCs) are unusual lesions, with about 130 cases reported in the literature. Although benign, they may involve the orbit and cause acute restrictive ophthalmoplegia, proptosis, and reduced visual acuity. METHODS AND RESULTS: We present three cases (1 male, 2 females, aged 35, 36, and 46 years) of orbital involvement with acute decreased visual acuity by SMC. The lesions were promptly excised via a transnasal approach to decompress the optic nerve. After the decompression, the patients recovered completely. CONCLUSION: We believe that immediate surgical drainage of the SMC and prolonged antibiotic therapy are necessary and resulted in recovery of visual acuity. Prompt microsurgical transsphenoidal decompression is simple, effective, safe, and is necessary for avoiding persistent visual loss. Antibiotic therapy alone usually results in a poor outcome. We discuss the etiology, clinical manifestations, and management of this rare condition in the light of 130 other cases in the literature.

Bypass-surgery and coil-embolisation in the treatment of cerebral giant aneurysms.

OBJECTIVE: Operative clipping is the most effective method in the treatment of cerebral giant aneurysms. But about 50% of all giant aneurysms are treatable this way. We want to report about eight patients with giant cerebral aneurysms, which were in our opinion "unclippable" without causing ischaemia in depending brain areas. METHODS: We describe eight cases of giant aneurysms of the pericallosal artery (n = 1) the middle cerebral artery (n = 3), the basilar tip (n = 3) and of the upper part of the basilar artery (n = 1). One patient with an aneurysm of the pericallosal artery was treated with an extra-intracranial saphenous vein bypass saphenous bypass, in three cases of middle cerebral artery aneurysms an extra-intracranial bypass was also done combined with a resection of the aneurysm. The four patients suffering from an aneurysm of the basilar artery got an extra intracranial bypass too followed by an occlusion of the aneurysm with GD-Coils. RESULTS: There was no peri-operative mortality and no severe peri- or postoperative complication. The neurological symptoms of all patients were unchanged after the operation. An angiographic control showed a complete obliteration of the aneurysm and a free running bypass in all cases. CONCLUSION: Bypass surgery and combined bypass surgery and coil embolisation are effective methods in the treatment of giant cerebral aneurysms, which can not be treated by clipping alone.

Delayed ischemic optic neuropathy after surgery on skull base meningiomas successfully treated with nimodipine and rheological therapy: report of two cases.

Two patients operated on because of skull base meningiomas experienced delayed ischemic optic neuropathy with loss of vision in one eye on days 6 and 12 after surgery. Treatment with nimodipine and rheological therapy was effective in restoring visual acuity. Possible pathophysiological mechanisms and treatment options are discussed.

Brain tumor surgery in geriatric patients: a critical analysis in 44 patients over 80 years.

BACKGROUND: The decision of whether to operate on brain tumors in elderly patients has not been made easier despite diagnostic and therapeutic advances facilitating their diagnosis. Little is known about the outcome of brain tumor surgery in patients 80 years or older probably because the number of these patients, although increasing, is still small. METHODS: The results of brain tumor surgery in 44 patients aged 80-86 years (mean age 83 years) were analyzed to determine which factors are relevant in the evaluation of the operative risk. The following parameters were analyzed with regard to the outcome: tumor volume, location, histopathology, preoperative condition, and concomitant diseases. RESULTS: At discharge 19 patients (43%) had improved while 14 (32%) remained unchanged. Nevertheless, the overall results were unsatisfactory in 10 patients (23%), of whom 5 died in hospital. Tumor location, volume, and histopathology did not correlate with the outcome. The preoperative cerebrovascular condition and the existence of multiple concomitant diseases were clearly the determining factors for the outcome. CONCLUSIONS: These results indicate that patients with life-threatening tumors or those causing persistent and intolerable brain dysfunction suffering from symptomatic cerebrovascular atherosclerosis as well as from multiple treatment requiring concomitant diseases did definitely not benefit from surgery.

CT and MRI of congenital sinonasal ossifying fibroma.

We report a 9-year-old boy with a sinonasal ossifying fibroma, probably congenital, with atypical findings on CT and MRI. CT revealed a soft-tissue density mass in the sphenoethmoidal sinuses, nasal cavity and right maxillary sinus with a few foci of calcification and with remodelling and destruction of the adjacent facial bones. MRI showed high signal on T2- and intermediate signal on T1-weighted images. A thin, partly enhancing outer shell and some nonenhancing septa were visible on contrast-enhanced images. MRI also showed the tumour to extend into the anterior cranial fossa. Subtotal removal was performed. We compare our findings with reports in the literature and discuss the differences from fibrous dysplasia.

Orbital and cerebral cavernomas: comparison of clinical, neuroimaging, and neuropathological features.

Our results with 15 orbital cavernomas showed that there are important differences in comparison with cerebral cavernomas: in contrast all orbital cavernomas were embedded by a lilac hard and compact capsule. Clinical symptoms were characterized by the growth of the orbital cavernomas. There were no signs of hemorrhage, which is typical for cerebral cavernomas. The latter showed in contrast to orbital cavernomas a degenerated collagenous tissue forming the vessel walls. The capsule of the orbital cavernomas can be proved by magnetic resonance imaging (MRI). Because of its tendency to lead to irreversible loss of visual acuity, we recommend early surgery after the onset of symptoms.

New device to treat chronic subdural hematoma--hollow screw.

Different surgical approaches exist for the treatment of chronic subdural hematoma. None of these approaches is superior to the other, so a minimal-invasive device (a hollow screw) was developed. The system consists of a stable hollow screw of surgical steel with a perforated tip, a hand-drill, screwdriver with guide, and collection bag. To place the screw in the skull local anesthesia is necessary followed by stab incision and percutaneous trephination. The screw is then placed in the bone and the guide removed. After spontaneous drainage and irrigation, a closed drainage system with a collection bag is connected with the screw. First results with the new technology are promising, with a high rate of completely treated patients and a low rate of complications. Two of 86 patients had a local skin infection after implantation of the screw, and in 22 patients the procedure was repeated due to one or more cases of recurrent or residual hematoma. No neurological deterioration was caused by the screw or the surgical approach. The advantages of this new system are: quick and simple procedure, minimal invasive, excellent function, inexpensive and reusable.

[Median craniofacial clefts. Therapy recommendations and late outcome]. / Mediane kraniofaziale Spalten. Therapieempfehlungen und Spätergebnisse.

Median craniofacial clefts are classified as median facian cleft deformities and are characterized by clefts of the nose involving the skull base. They can be accompanied by hypertelorism and/or encephaloceles. From a total of 22 of our patients with median deformities, three encephaloceles and two severe median nasal clefts with hypertelorism were considered in 2- to-8-year-olds. Two children with severe brain deformities died before the commencement of therapy. The remaining median deformities were corrected as soon as possible, whereby exclusively soft-tissue surgery was performed during the first year of life and in no case later than school admittance. Final corrections on the nasal skeleton were made after the age of 12. No growth disturbances of the middle face or jaw occurred subsequent to craniotomies and corrections of hypertelorism. Plate osteosynthesis has proven to be the most reliable method of stabilization; we removed the osteosynthetic material in all cases. The multiplicity of possible deformities requires that procedures be tailored to the individual case.

Microsurgical treatment of intramedullary spinal cord tumors.

Eighty patients with intramedullary spinal cord tumors were treated by microsurgical methods between 1988 and 1996. Twenty-nine patients were diagnosed with astrocytoma, 36 with ependymoma, five with metastasis, four with lipoma, three with dermoid or epidermoid tumor, two with neurofibroma, and one with neuroma. Vascular and infectious lesions (such as abscesses and hemangioblastomas) were excluded. After laminectomy, total removal of the lesion was achieved in 68 of 80 patients and subtotal removal in 12. Postoperative radiation therapy was performed in 13 of 80 patients. The follow-up period ranged from 12 to 92 months (mean 42.2 months). All patients underwent preoperative and postoperative magnetic resonance imaging at intervals ranging from 3 months to 5 years postoperatively. Four patients showed clinical and radiological evidence of local tumor recurrence during the follow-up period. Four patients died 5 months to 15 months postoperatively from the re-expansion of their primary metastatic disease. The operative results at long term (after the 6th postoperative month) were better than the results at short term (before the 6th postoperative month) and revealed clinical improvement in 63, no change in 10, and deterioration in seven patients. We recommend early radical surgery, whenever possible, to be performed when the patient's neurological status is still good. Subtotal removal and irradiation are better for malignant or metastatic tumors. Partial decompressive removal is best for large intramedullary lipomas. Plastic laminotomy with preservation of the intervertebral joints is especially recommended in young or middle-aged patients.

Spondylodiscitis after lumbar discectomy. Incidence and a proposal for prophylaxis.

STUDY DESIGN: An analysis of the incidence of spondylodiscitis after lumbar disc surgery in 1642 patients. In 508 patients no prophylactic antibiotics were given. In 1134 patients a collagenous sponge containing gentamicin was placed in the cleared disc space. OBJECTIVES: To report the incidence of postoperative spondylodiscitis in cases in which no antibiotic prophylaxis was used, and to define the value of a collagenous sponge containing gentamicin in preventing disc space infections. SUMMARY OF BACKGROUND DATA: Spondylodiscitis is considered to be a rare complication of lumbar disc surgery. The retrospective design of most studies and the rare use of magnetic resonance imaging for early radiologic diagnosis suggest that the reported incidence rates may be underestimates. Postoperative spondylodiscitis is the result of intraoperative contamination and, theoretically, could be prevented by treating these patients with prophylactic antibiotics. METHODS: In 1642 patients, 1712 discectomies were performed. In 508 of these patients no prophylactic antibiotics were given; in 1134 of these patients a collagenous sponge containing gentamicin was placed in the cleared disc space. Clinical reexamination and, in cases of unsatisfactory results, laboratory and radiologic investigations were performed 4-8 weeks after surgery. RESULTS: In nineteen of the 508 patients who were not treated with antibiotic prophylaxis (3.7%) a postoperative spondylodiscitis developed, whereas none of the 1134 patients who received antibiotic prophylaxis became symptomatic (P < 0.00001). CONCLUSION: In the current study, a 3.7% incidence of postoperative spondylodiscitis was found in the absence of prophylactic antibiotics. Gentamicin-containing collagenous sponges placed in the cleared disc space were effective in preventing postoperative spondylodiscitis.