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.

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.

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.

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.

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.

Pterional approach to the contralateral orbit.

Of a total of 80 operated intraorbital lesions, 2 were located in the posterior intraconal space, medial and inferior to the optic nerve. Because they were unfavorably located for standard surgical approaches, we operated via a contralateral pterional transsphenoidal-transethmoidal route. This technique provided excellent exposure and results in these two cases of intraorbital cavernous malformations. A brief description of the approach is presented.

[Aneurysm of the vein of Galen as a possible cause of congestive heart failure: a report of 5 new cases]. / Aneurysma der Vena Galeni als mögliche Ursache für eine kongestive Herzinsuffizienz: Bericht über 5 neue Fälle.

We report on five newborns with an arterio-venous malformation of the vein of Galen. All newborns were cyanotic and in congestive heart failure without any evidence of congenital heart disease. Congestive heart failure in these cases was mainly due to an almost two-fold increase in cardiac output of approximately 8 l/min/m2 (normal: 4.5 l/min/m2). According to previous reports, mortality is very high in patients with this malformation when becoming symptomatic during infancy, and therapy by surgery or embolization is only successful in 10-30%. While three of our patients died shortly after diagnosis because of untreatable heart failure, the other two were operated on either by subtotal ligation of the draining vein or by ligation of 4 arterial feeders. In the first case secondary thrombosis of the aneurysm occurred and cardiac failure subsided. In the second case a large shunt remained and a balloon-embolization was performed successfully. However, in both patients severe neurologic defects occurred, the severity of which remains to be assessed later since the post-operative observation period is only 2 and 5 months, respectively.

Intraoperative Doppler and real time sonography in neurosurgery.

Ultrasound Doppler sonography with miniaturized probes and high resolution offers new possibilities of intraoperative control of neurovascular procedures. Patency, flow direction stenoses and changes in resistance can be investigated atraumatically, repeatedly and without additional preparation. In bypass and aneurysm surgery, about 10% of the cases were shown by Doppler examinations to be unsatisfactory, with stenoses and occlusions. These could be immediately corrected without loss of time. In normal cases, the information on the local haemodynamics enlarges the knowledge as to the effects of the operation and make it safer. Real time ultrasonography, which can be easily adapted to neurosurgery, is a new atraumatic tool for localizing, in two dimensions, subcortical intrinsic processes, haematomas, ventricles ect. It is useful for guided biopsies and punctures and for the centering of the dura and brain incision over the middle of the lesion, especially in microsurgical procedures.