De novo aneurysm of the anterior communicating artery presenting with subarachnoid hemorrhage 7 years after initial cryptogenic subarachnoid hemorrhage: a case report and review of the literature.

Spontaneous subarachnoid hemorrhage (SAH) is usually caused by a ruptured cerebral aneurysm. Despite the use of initial four-vessel cerebral digital subtraction angiography (DSA), 15 % of all cases remain idiopathic. According to the initial computed tomographic scan, the spontaneous SAH can be divided into a perimesencephalic group associated with a benign nature and a nonperimesencephalic group with a similar clinical course as aneurysmal SAH. We present a case of a 49-year-old man with a de novo aneurysm formation of the anterior communicating artery with SAH 7 years after initial cryptogenic nonperimesencephalic SAH. This observation suggests that in some cases, long-term angiographic studies might be justified.

Prolonged administration of temozolomide in adult patients with anaplastic glioma.

PURPOSE: Prolonged administration of temozolomide is widely used in patients with glioblastoma; whereas the treatment of anaplastic glioma differs between neurooncological centres. The safety, feasibility and efficacy of prolonged temozolomide administration in patients with anaplastic gliomas was evaluated. PATIENTS AND METHODS: Forty-two patients with primary, recurrent or secondary anaplastic glioma were retrospectively analysed for the course of their disease. Treatment mostly consisted of surgery, followed by radiotherapy with concomitant and adjuvant temozolomide. In five patients with recurrence of primary anaplastic glioma, chemotherapy was initiated without previous surgery. Temozolomide was administered until evidence of tumour recurrence, appearance of serious side-effects or patients' wish to finish chemotherapy. RESULTS: The median overall survival (OS) was 39 months with a median cycle number of 7.5 (1-42). Treatment with temozolomide was stopped in 12 patients due to side-effects in general, whereas in only three patients (7.1%) treatment had to be discontinued due to haematological side-effects. There was no evidence of treatment related infections or grade IV toxicity. Extent of surgery had a significant influence on OS in anaplastic gliomas, the number of adjuvant temozolomide cycles showed a positive influence as well on time to progression (TTP) and OS. CONCLUSION: Prolonged administration of adjuvant temozolomide is safe and can be favorable for patients with anaplastic gliomas.

Effect of mouth opening on bypass function after combined revascularization for Moyamoya disease.

Moyamoya disease represents a rare steno-occlusive disease of the internal carotid artery (ICA) with a reactive and pathological basal network of collateral vessels. It may lead to ischemic stroke or intracerebral hemorrhage. Treatment options are either direct or indirect revascularization procedures or a combination thereof. Specialized centers report sufficient revascularization in most patients and low complication rates.Between 2005 and 2008, direct extra-intracranial bypass surgery in combination with encephalomyosynangiosis (EMS) was performed in 71 Moyamoya patients at the Mannheim University Medical Center.Following one case of reversible neurological deficits associated with mouth opening, we prospectively evaluated the effect of mouth opening on bypass function in this patient and four further consecutive patients by digital subtraction angiography.Three out of five patients showed alterations in bypass patency upon mouth opening. The obstruction was located at the junction of the bypass and the temporal muscle. Two temporary occlusions and one case of decreased flow were observed. One patient demonstrated reversible hemiparesis and aphasia.

Microembolic signal monitoring after coiling of unruptured cerebral aneurysms: an observational analysis of 123 cases.

BACKGROUND AND PURPOSE: Thromboembolic events after aneurysm coiling are common, but the optimal algorithm for emboli prevention remains unclear. MESs correlate with the occurrence of impending ischemic events and may be used for management guidance. This study reports the use of MES monitoring with regard to aneurysm characteristics and coiling technique after a specific anticoagulation protocol. MATERIALS AND METHODS: We analyzed 123 consecutive, elective endovascular procedures. Patients received intraprocedural and continuous heparin if feasible. Demographic data, aneurysm size, type of intervention/complication, medication, imaging, and clinical outcome were analyzed. MES monitoring was performed in all patients both immediately after as well as >12 hours after the procedure. RESULTS: Heparinization within the first 12 hours was associated with lower numbers of MESs early after coiling (3.4 versus 18.8 MESs/hr). When on heparin, larger aneurysm size, stent-assisted procedures, or incomplete occlusion did not lead to a significant increase in MESs. If the initial MES count on heparin was >10 MESs/hr, it was always safe to discontinue heparin. Inability to initiate early, continuous heparinization was associated with new neurologic deficits. Additional administration of antiplatelet agents showed lower MES counts initially, but the difference was not significant. CONCLUSIONS: MES monitoring is a powerful adjunct to monitor efficacy of treatment algorithms for emboli prevention after coiling. In our series, early heparinization was associated with a lower incidence of MESs. This is of particular importance in larger aneurysms, stent-assisted procedures, and incomplete occlusions, in which the thromboembolic risk is greatest early on and antiplatelet treatment alone may not suffice.

Management of patients with low-grade gliomas - a survey among German neurosurgical departments.

BACKGROUND AND AIMS OF THE STUDY: The diagnosis and treatment of low-grade gliomas (LGG) are multimodal. Today, there is no defined standard in diagnosis and treatment. Controversies are, in general, about a "wait-and-see" strategy, diagnostic workup, surgical intervention, postoperative imaging, adjuvant treatment, and follow-up. The aim of this study is to gain an overview about management strategies of high-volume German neurosurgical departments treating these patients. MATERIAL AND METHODS: A questionnaire including diagnostic, preoperative, perioperative, and postoperative parameters and 5 cases with magnetic resonance imaging data with questions to various treatment options in these patients was sent to all 34 German neurosurgical departments at university hospitals. RESULTS: In total, 24 questionnaires were returned and analysed. Centres were divided into those who generally practice a "wait-and-see" strategy vs. those who do not or only in highly selected cases. Statistical analyses were performed with Fisher test and Chi (2)-test. Interestingly, 50% of all centres routinely follow a "wait-and-see" strategy. CONCLUSION: Although the management of patients with LGG is complex and a simple questionnaire will not be able to define a standard in diagnosis and treatment, this study offers an overview on strategies at high-volume academic centres dealing with these patients. There is consensus to resect superficially located lobar and circumscribed low-grade lesions. However, the differences between centres become apparent with increasing complexity of the lesions.

Response to temozolomide in supratentorial multifocal recurrence of malignant ependymoma.

Intracranial anaplastic ependymomas are a very rare entity within the group of adult CNS neoplasms. Thus, no standard adjuvant therapy after surgical resection has been defined so far. External radiotherapy is commonly administered, but the role of chemotherapy is still unclear in malignant ependymomas. The case of a 25-year-old female patient with multifocal recurrence of a supratentorial malignant ependymoma administered temozolomide as second-line therapy is reported. Currently, 5 months after initiation of temozolomide treatment, there is no evidence of radiographic progression. Temozolomide could constitute a promising approach to supratentorial recurrent and multifocal anaplastic ependymoma of adults.

Neuro-endocrine and neuropsychological outcome after aneurysmal subarachnoid hemorrhage (aSAH): a prospective cohort study.

OBJECTIVE: Neuropsychological sequelae are common after aneurysmal subarachnoid hemorrhage (aSAH) and may be associated with or caused by supposed hypothalamic-pituitary dysfunction. We evaluated the incidence of neuro-endocrine and neuropsychological deficits after aSAH and their interrelations in a standardized manner. METHODS: 26 patients (20 females) were prospectively screened for neuro-endocrine and neuropsychological deficits 3 and 6 months after aSAH. We measured GH, IGF-1, prolactin, LH, FSH, estradiol, TSH, fT4, total T3, testosterone, ACTH as well as cortisol before and after ACTH-stimulation. Neuropsychological analysis covered verbal comprehension, short term and working memory, visuospatial construction, figural memory, psychomotor speed, attention, and concentration. RESULTS: After 3 months central hypogonadism was observed in 2 patients accompanied by central hypothyroidism in 1 male subject. Central hypogonadism resolved spontaneously after 6 months in both. After 3 months, neuropsychological deficits were detected in 57% of the examined patients (44% attention deficits, 38% memory impairment, 12% psychomotor deficits). Neuropsychological deficits were still present in 53% after 6 months. CONCLUSION: We found a low prevalence of neuro-endocrine and a high prevalence of neuropsychological deficits in patients 3 and 6 months after aSAH. Thus, the absent co-incidence of central hormonal and psychological dysfunction leaves a causal association questionable.

Dual-energy CT after peri-interventional subarachnoid haemorrhage: a feasibility study.

PURPOSE: The aim was to assess the feasibility of dual-energy computed tomography (DE-CT) for detection of peri-interventional re-bleeding in patients with aneurysmal subarachnoid hemorrhage (re-SAH). METHODS: For in vitro-analyses DE-CT of partially clotted blood intermixed with fresh blood containing contrast agent was performed. In a clinical setting, 4 patients routinely underwent DE-CT after suspected peri-interventional re-SAH. DE-CT source data images, iodine maps and virtual non-contrast images (VNC) were analyzed and regions-of-interest (ROI) measurements of density values were performed. RESULTS: In vitro experiments demonstrated the feasibility of DE-CT to discriminate between blood with and without contrast agent. In all patients peri-interventional re-SAH was confirmed by detection of extravasated iodine within the subarachnoid spaces in post-interventional DE-CT. Dual-energy CT allowed the discrimination of old blood clots of the initial SAH and blood originating from peri-interventional re-SAH. After subtraction of the iodine-related high density signal, VNC images optimized the estimation of the true amount of subarachnoid blood. CONCLUSION: Dual-energy CT allows the discrimination and subtraction of blood and iodine mixed within the subarachnoid spaces in patients with peri-interventional re-SAH. It helps to avoid overestimation of SAH after peri-interventional re-bleeding and therefore is a potentially valuable tool in the assessment of peri-interventional re-SAH.

SOM230 (pasireotide) and temozolomide achieve sustained control of tumour progression and ACTH secretion in pituitary carcinoma with widespread metastases.

Pituitary carcinomas are rare and neurosurgically challenging lesions, as they commonly relapse after surgical removal. Their prognosis is dismal due to their limited response to radiotherapy and chemotherapy. In recent studies, temozolomide was administered in very few patients with partial effects. We report a patient with an ACTH-secreting pituitary carcinoma and widespread intracranial, spinal and systemic metastases despite repeated surgical treatment, bilateral adrenalectomy, medical treatment and radiotherapy. Additionally to chemotherapy with temozolomide, the patient received SOM230 as salvage therapy with an improvement of the patient's clinical status, and a reduction of ACTH levels. After 12 months of combination therapy a sustained tumor control was achieved and persisted upon monotherapy with SOM230 for more than 9 months thereafter. Thus, temozolomide in combination with SOM230 seems to be promising in patients with ACTH-secreting metastasized pituitary carcinoma.

[Translaminar fenestration for caudally herniated lumbar discs--a technical note]. / Translaminäre Fensterung bei nach kaudal sequestriertem lumbalem Bandscheibenvorfall--Technische Mitteilung.

Translaminar approaches have been described for lumbar disc herniations which are displaced cranially or laterally into the neuroforamen. This technique provides the advantages of a minimally invasive approach with regard to postoperative instability or partial facet joint resection and avoids a medial arthrectomy. We describe this technique for the first time as an option for a caudally sequestrated disc herniation via a transaxillar sequesterotomy.

Combination of a supratentorial venous anomaly and infratentorial developmental venous anomalies mimicking AV-malformation: a case report.

Developmental venous anomalies (DVAs) are considered to be congenital anatomical variants of venous drainage. In most cases unspecific symptoms lead to their diagnosis. We describe a 35-year-old patient presenting with headache and dizziness. MRI was suspicious for arteriovenous malformation and the dorsal horn of the right lateral ventricle was enlarged. Digital subtraction angiography showed complex venous malformations with abnormal supratentorial venous drainage and bilateral cerebellar DVAs with associated varix nodes. This is a unique case of complex supra- and infratentorial abnormal venous drainage. After considering the complexity of these venous anomalies and the fact that the patient was asymptomatic there was no reasonable indication for treatment.

Alveolar rhabdomyosarcoma of the clivus with intrasellar expansion: Case report.

Rhabdomyosarcomas are common tumors of the head and neck region in children. However, a primarily intracranial localization of this tumor entity is rare. We report on a 3-year-old boy presenting with double vision due to left VI (th) nerve palsy. No other neurological deficits were recognized by clinical inspection. MRI scans visualized an enhancing mass lesion in the upper clivus compressing the cavernous sinus and the pituitary gland. Transsphenoidal biopsy was performed and histopathological examination as well as molecular diagnostics confirmed the diagnosis of an alveolar rhabdomyosarcoma (ARMS). Staging identified a metastatic lesion in the fourth thoracic vertebra resulting in the diagnosis of stage IV disease. Treatment modality included stereotactic radio- and chemotherapy.