Functional outcome in patients after excision of extracanalicular acoustic neuromas using the suboccipital approach.

An audit of surgery for acoustic neuroma was carried out to determine the frequency and nature of postoperative symptoms and their impact upon the patient's quality of life and vocation. Fifty-six patients were interviewed between 6 months and 5 years (mean 26 months) after surgical excision of an acoustic neuroma. The objective surgical results in these patients are good, with normal or near normal functional preservation rates of 80% for the facial nerve (House-Brackmann grade I/II), and 27.3% for a previously functioning acoustic nerve. Despite this there was no significant overall reduction in the reported occurrence of balance problems, tinnitus, headache and other neurological sequelae of the tumour after surgical excision. In 20% of the patients persistent symptoms, including deafness and facial weakness, had prevented the resumption of former social activities. As a result of these symptoms 8.6% of the patients were certified medically unfit for work, but of those employed preoperatively over 70% had returned to their jobs. The success of neuro-otological surgical management of acoustic neuroma is offset by some degree of chronic morbidity. Our patients expressed the need to know whether their symptoms would resolve, but were often too afraid to ask. Patients can be reassured that the majority resume their former social and vocational activities, but should be advised that some symptoms can persist or occur de novo after surgery. Our data suggest that early intervention would reduce the incidence of these troublesome sequelae.

Successful removal of intramedullary spinal cord metastasis: case report.

Intramedullary metastatic disease accounts for 5% of CNS metastases. This report describes a 47-year-old female with the simultaneous presentation of primary breast carcinoma and a solitary brain metastasis, both treated surgically. She represented with an increasing hemiparesis due to a spinal cord metastasis 4 years later. The cord lesion was removed microsurgically using a CO2 laser. Postoperatively she made a good recovery and lived independently for 2 years. The rationale for aggressive surgical treatment is discussed.

MRI in the diagnosis of spinal extradural angiolipoma.

We report the case of a 68-year-old woman with a 1-year history of progressive spastic paraparesis, due to an extradural angiolipoma of the mid-thoracic spine. The MRI appearance of the angiolipoma is reported here for the first time. This appearance is characteristic, allows preoperative diagnosis and assists planning of the surgical approach.

Postoperative recovery of third nerve palsy due to posterior communicating aneurysms.

Postoperative recovery of third nerve palsy due to a posterior communicating artery aneurysm was correlated with pre- and intraoperative factors. The only significant factor determining recovery was the degree of preoperative deficit. The presence of subarachnoid haemorrhage, timing of surgery and aspiration of the aneurysmal sac did not influence recovery.

Subependymomas of the fourth ventricle. Surgical treatment in 12 cases.

Subependymomas of the fourth ventricle are generally considered incidental postmortem findings, and have received scant attention from neurosurgeons. The authors present a surgical series of 12 cases of this disorder diagnosed over a 13-year period. The clinical and radiological findings were reviewed and correlations made with pathological studies. The subependymoma is a histologically benign tumor that tends to be calcified. It has a predilection for the fourth ventricle and a peak incidence in the fifth decade of life. It is usually of considerable size with extensive attachment at the time of its detection, and is associated with significant surgical morbidity. The authors believe that magnetic resonance imaging may be the best method of investigation. Intraoperative disturbance of circulatory or respiratory control should suggest to the surgeon that the operation be abandoned. A laser or ultrasonic aspirator may be very helpful in removing these tumors. Postoperative care must include monitoring for apnea.

Isodense colloid cysts of the third ventricle: a diagnostic and therapeutic problem resolved by ventriculoscopy.

Eighteen patients with a colloid cyst of the 3rd ventricle presented to the Frenchay Hospital Neurosurgery Unit. The investigations included computed tomography (CT). Of these patients, 9 had radiographically isodense cysts that caused considerable diagnostic difficulties, being described only as an anterior 3rd ventricular space-occupying lesion and lateral ventricular dilatation in all but 2 cases. The clinical findings are described and the CT appearance is discussed. The new use of ventriculoscopy may resolve the problem rapidly; ventriculoscopy made the diagnosis in 5 cases and confirmed a CT diagnosis in 3 others. (It has also confirmed the diagnosis in 2 cases of hyperdense cysts.) Lately, it has been possible to aspirate the cyst contents endoscopically or, if the colloid is too viscous, to remove it with endoscopic rongeurs. After either of these procedures, the cyst wall can be coagulated with diathermy endoscopically. The method is described, and the advantages over other investigations and treatment are discussed.

Simple practical techniques in the management of urinary incontinence.

Surgery for incontinence should be reserved for specific indications where its value as a primary treatment has been proven. Otherwise surgery should not be employed until a wide range of conservative treatments have been tried and have failed. The conservative methods of management outlined below include "bladder training' using frequency/volume charts to monitor, and alter, the pattern of micturition and number of episodes of incontinence, re-education of the pelvic floor muscles, intermittent self-catheterization, hormone replacement therapy, regulation of fluid intake and bowel habit, discriminate use of diuretics and hypnotics and adjustments to domestic conditions.

Urethral closure pressure profiles in the male: an analysis of 280 patients.

The shape of the urethral closure pressure profile of 281 male patients has been analysed. 'Prostatic' length, 'prostatic' peak, 'prostatic' plateau height and 'prostatic' plateau area have been measured. Thist study has shown that these parameters have a significant relation to the diagnosis of bladder outflow obstruction made after urodynamic studies.

Management of the uninhibited bladder by selective sacral neurectomy.

The authors report the treatment of incontinence due to uninhibited bladder contractions by selective sacral neurectomy in nine patients, four without evidence of neurological disease. A detailed and objective analysis of bladder and urethral function, together with quantitation of clinical features, was made before and after operation. Seven patients were either cured or greatly improved. The overall increase in bladder capacity and reduction of uninhibited activity were statistically significant. The resting urethral sphincter pressure was unchanged, but the contractility of the voluntary external sphincter was slightly impaired. Criteria for such neurectomies are discussed.

Intracerebral pneumatocele: an unusual complication following intraventricular drainage in case of benign intracranial hypertension.

The development of an intracerebral pneumatocele following ventricular catheterization for benign intracranial hypertension is described. The importance of skull radiography in the diagnosis of this previously unreported complication ist emphasized. This case demonstrates that air can accumulate without the need to implicate increased pharyngeal pressure, and despite raised intracranial pressure.

The urodynamic assessment of adult enuresis.

Urodynamic analysis has revealed a high proportion of uninhibited bladder activity in adult enuresis. There was no associated neurological deficit to explain this abnormality. There was no correlation between the various diurnal symptoms and the presence of uninhibited bladder contractions. Enuresis was associated with obstructive uropathy in only 6 percent of cases. Some evidence has also been presented to support the concepts of ectopic sensory receptors and abnormal sphincter inhibition. A review of the problem of pathogenesis has suggested four main areas of possible abnormality: 1. A sensory lesion producing inadequate or delayed appreciation of bladder activity. 2. Cortical and subcortical dysfunction because of inadequate arousal or defective maturation of subconscious inhibition. 3. A congenital or acquired upper motor neurone lesion causing an uninhibited bladder. 4. A similar or related lesion causing an over-inhibited sphincter. These factors probably always occur in varying combinations. Because of the lack of association between symptoms, signs and objective measurements, there is a strong case for relating diagnosis, prognosis and treatment to urodynamic assessment.

Urodynamic analysis of differential sacral nerve blocks and sacral neurectomy.

Urodynamic analysis in 17 patients after long-acting anaesthetic root blocks of S2-S4 has shown that it is possible to increase bladder capacity and reduce uninhibited contractions without significant adverse effects on sphincter function. Satisfactory voiding dynamics are observed after blocks. This has provided a physiological rationale for selective sacral neurectomy in eight patients. Initial improvement after operation has been noted in seven cases.