[An old woman with sudden pareses and blindness]. / En eldre kvinne med akutte pareser og synstap.

We present a patient with Posterior Reversible Encephalopathy Syndrome (PRES). A 74-year-old woman was admitted with sepsis, which originated from erysipelas on her neck the following day. She developed respiratory obstruction due to oedema, septic shock, disseminated intravascular coagulation (DIC), acute renal failure and atrial fibrillation. She responded well to treatment and improved rapidly, despite of her serious condition. When she had almost fully recovered after 15 days, her general condition worsened, and she developed confusion, blindness and pareses. MRI showed vasogenic oedema in the parietooccipital regions of the brain and in the cerebellum, consistent with PRES. PRES is a clinical and radiological diagnosis consisting of headache, confusion, cortical blindness, convulsions and sometimes pareses. MRI of the cerebrum with diffusion-weighted imaging (DWI) and Apparent Diffusion Coefficient (ADC) map are decisive to the diagnosis, and usually shows a characteristic bilateral vasogenic oedema in the parietooccipital region. This can distinguish PRES from brain infarction, which shows a cytotoxic oedema on MRI. We discuss our patient in the light of different conditions leading to PRES, possible pathophysiological factors and treatment options.

Transpterygoid Trans-sphenoid Approach to the Lateral Extension of the Sphenoid Sinus to Repair a Spontaneous CSF Leak.

OBJECTIVE AND IMPORTANCE: Cerebrospinal fluid (CSF) fistula from the middle cranial fossa into the sphenoid sinus is a rare condition. In the past, the treatment of choice has been closure via a craniotomy. Only few geriatric cases are known, which were successfully operated by endoscopic surgery. We present a further case of nontraumatic CSF fistula originating from the middle cranial fossa. A new endoscopic technique was applied. We discuss treatment options for this rare defect. CLINICAL PRESENTATION: A 76-year-old patient presented with a 2-year history of rhinorrhea. High levels of beta-trace protein pointed to a diagnosis of CSF fistula. The defect was located at the anterior and inferior aspect of the pterygoid recess of the left sphenoid sinus. INTERVENTION: The patient was operated using an endoscopic trans-sphenoidal approach. After endoscopic opening of the maxillary and sphenoid sinus, a complete posterior ethmoidectomy was performed. The medial part of the pterygoid process was removed, allowing endoscopic exposure and closure of the defect. At 1-year follow-up, the CSF fistula had not recurred and the patient had no sequel from the surgical procedure. CONCLUSION: In selected cases, this new endoscopic partial transpterygoid approach to the middle cranial fossa is recommended for surgical repair of CSF fistula involving the lateral extension of the sphenoid sinus. To our knowledge, ours is the oldest patient with this condition successfully operated by endoscopic means at the world's most northern university hospital.

[Treatment of intracranial aneurysms]. / Behandling av intrakraniale aneurismer.

BACKGROUND: The department of neurosurgery at the University Hospital of North Norway has treated intracranial aneurysms since 1986. This study was conducted in order to evaluate outcomes after the introduction of endovascular therapy in 2000. MATERIAL AND METHODS: We included all patients treated for intracranial aneurysms during the years 1999 through 2002 in a retrospective, cross-sectional study. Data were collected from patient files. RESULTS: We treated 113 aneurysms in 104 patients in 108 procedures. 81 (78 %) patients were treated after a subarachnoid haemorrhage, while 23 (22 %) underwent treatment of an unruptured aneurysm. 75 (66 %) aneurysms were operated with craniotomy and clipping of the aneurysm neck, 38 (34 %) were treated with coiling. The choice of modality was dependent on the location and shape of the lesion. Complications related to the treatment were more common after surgical treatment than after coiling (41 versus 16 %, p=0.009), but the method of treatment did not influence long-term outcome evaluated according to the Glasgow Outcome Scale (GOS). All patients who underwent treatment for an unruptured aneurysm achieved a good outcome (GOS score 4 or 5), while patients treated after subarachnoid haemorrhage experienced significantly (p = 0.003) less favourable outcomes. Regression analysis revealed poor clinical condition (high Hunt & Hess grades) after the haemorrhage as the only independent predictor of outcome. INTERPRETATION: The university hospital has treated an increasing proportion of patients with intracranial aneurysms with endovascular coiling after introduction of this method in 2000. The outcomes presented in this study equal those published from international multicentre trials.