Hypopituitarism following severe traumatic brain injury.

Although hypopituitarism is a known complication of traumatic head injury, it may be under-recognized due to its subtle clinical manifestations. To address this issue, we determine the prevalence of neuroendocrine abnormalities in patients rehabilitating from severe traumatic brain injury (Glasgow Coma Scale < or = 8). 76 patients (mean age 39 +/- 14 yr; range 18-65; 53 males and 23 females; BMI 25.8 +/- 4.2 kg/m2; mean +/- SD) with a severe traumatic brain injury, an average of 22 +/- 10 months before this study (median, 20 months), underwent a series of standard endocrine tests, including TSH, free T4, T4, T3, prolactin, testosterone (males), estradiol (females), cortisol, ACTH, GH, and IGF-I. All subjects also underwent GH response to GHRH + arginine. Growth hormone deficiency (GHD) was defined as a GH response < 9 microg/L to GHRH + arginine and was confirmed by ITT (< 3 microg/L). Pituitary deficiency was shown in 24% of the patients (18/76). 8% (n = 6) had GHD (GH-peak range [GHRH + arginine]: 2.8-6.3 microg/L; GH-peak range [ITT]: 1.5-2.2 microg/L; IGF-I range: 62-174 microg/L). 17% (n = 13) had hypogonadism (total testosterone < 9.5 nmol/L and low gonadotropins in 12 males; low estradiol, and low gonadotropins in 1 female). Total testosterone levels did not correlate with BMI or age. 2 males with hypogonadism also showed a mild hyperprolactinemia (33 and 41 ng/ml). 3% (n = 2) patients had partial ACTH-deficiency (cortisol-peak [ITT] 392 and 417 nmol/L) and 3% (n = 2) had TSH-deficiency. In summary, we have found hypopituitarism in one-fourth of patients with predominantly secondary hypogonadism and GHD. These findings strongly suggest that patients who suffer head trauma must routinely include neuroendocrine evaluations.

Endovascular treatment of middle cerebral artery aneurysms with electrolytically detachable coils.

BACKGROUND AND PURPOSE: Middle cerebral artery (MCA) aneurysms often have an unfavorable aneurysm geometry that might limit endovascular therapy. Our purpose was to analyze the feasibility, safety, and efficacy of coil embolization in a consecutive series of MCA aneurysms chosen for endovascular treatment. PATIENTS AND TECHNIQUES: Of 235 MCA aneurysms seen at our institution during the past 5 years, 36 patients harboring 38 MCA aneurysms were primarily selected for coil embolization: 18 patients had an acute subarachnoid hemorrhage (SAH), 16 of which were due to a ruptured MCA aneurysm. SAH was classified according to Hunt and Hess grade: I (5), II (7), III (5), IV (0), and V (1). RESULTS: Complete occlusion could be achieved in 33 of 38 aneurysms. In 5 aneurysms, coil embolization was not performed because of an unfavorable aneurysm geometry with a wide neck or incorporation of adjacent branches (3) or failed because of insecure coil placement (1) or severe vasospasm (1). Procedural complications included coil protrusion into the parent artery (1), and thromboembolic M2 occlusion (5), with recanalization in 4 of 5 cases. Of 8 aneurysms with initial subtotal occlusion, 3 progressed to total occlusion during follow-up. Three aneurysms had to be retreated, and no patient rebled. Glasgow Outcome Scale at 6 months for the patients with SAH (17/18) was good recovery (12), moderate disability (4), severe disability (0), persistent vegetative state (0), and death (1); outcomes for patients with an incidental aneurysm (17/18) were good recovery (16) and moderate disability (1). CONCLUSION: Endovascular coil embolization can be performed safely and effectively in selected MCA aneurysms. Initial subtotal aneurysm occlusion might progress to total occlusion.

Malignant meningioma as a second malignancy after therapy for acute lymphatic leukemia without cranial radiation.

RATIONALE: Meningiomas in the pediatric age group are very rare tumors, comprising about 1-4.2% of all primary pediatric intracranial tumors. CASE REPORT: We present a 17-year-old patient who suffered from an intraventricular malignant meningioma. At the age of 2 years, acute lymphatic leukemia (common ALL [cALL]) was diagnosed and successfully treated with chemotherapy. There was no cranial radiation therapy. In December 2001, 13 years after diagnosis of cALL, he complained of headache, vomiting, and walking difficulties. Magnetic resonance imaging showed an enhancing mass with cystic components in the trigone of the right lateral ventricle. The tumor was removed completely. Histological diagnosis revealed a malignant papillary meningioma. After removal of a recurrent meningioma 16 months later, he received local radiotherapy. CONCLUSION: Pathogenetic mechanisms, treatment options, and prognosis of meningiomas and secondary malignancies of this age group are discussed.

Surgical treatment of intramedullary spinal cord metastases of systemic cancer: functional outcome and prognosis.

OBJECTIVE: Intramedullary spinal cord metastases (ISCM) of systemic cancer are rare. To date, patients with ISCM tend to benefit only to a limited extend from surgery and adjuvant therapy. Subject of this investigation is to assess predictive factors for surgical outcome and survival and to evaluate the value of surgical radicality in the treatment of ISCM. PATIENTS AND METHODS: Between 1990 and 2004, a series of 146 patients with intramedullary tumors underwent surgical treatment in our institution. Among these, 13 patients with intramedullary cancer metastases (7 adenocarcinomas, 3 poorly differentiated carcinomas, 3 sarcomas) were identified. Standard microsurgical removal of the ISCM was performed. Functional outcome was graded according to a standardized scale and factors influencing outcome and survival were statistically analyzed. RESULTS: Median progression-free survival was 13 weeks and median overall survival was 31 weeks. In 5 patients (38) the intramedullary lesion was the initial manifestation of the malignant disease. All poorly differentiated carcinomas and all sarcomas were resected incompletely. Surgical radicality presented a negative predictive factor for functional outcome, increasing radicality leading to functional deterioration. Age, sex, tumor localization, surgical radicality and the presence of neoplastic meningeosis did not affect survival. CONCLUSION: Surgery of ISCM can be performed with an acceptable operative morbidity. Radicality depended on tumor histology. However, radical tumor removal did not affect survival and was correlated with a poor functional outcome. Therefore, complete surgical removal of ISCM should only be intended in patients in whom an unproblematic excision is feasible.

Functional outcome after surgical treatment of intramedullary spinal cord tumors: experience with 78 patients.

OBJECTIVE: To analyze factors with impact on the functional outcome for patients with surgically treated intramedullary spinal cord tumors (IMSCT) and to point out characteristics of the different histological entities. SETTING: Neurosurgical Department, University of Essen, Germany. METHODS: Between 1990 and 2000, a consecutive series of 78 patients were referred to our institution and underwent surgical treatment. There were 46 (59%) male and 32 (41%) female patients. Mean age was 43.3 years. Functional outcome was analyzed depending on histological features, age, tumor localization and the extension of involved spinal segments. The mean follow-up period was 34.4 months. Operative removal of the IMSCT was performed under standard microsurgical conditions with intraoperative monitoring of somatosensory-evoked potentials (SSEP). RESULTS: The most frequently involved localization was the cervical and cervicothoracic region (55%) followed by the thoracic region (32%) and the medullar conus (13%). The most frequent IMSCTs were neuroepithelial tumors in 44 patients (56.5%) including 32 patients with ependymomas, 15 astrocytomas, and two lesions without further histological classification. Non-neuroepithelial tumors included 10 metastases, nine cavernomas, eight hemangioblastomas, one dermoidal cyst and one enterogenetic cyst. Complete tumor removal was achieved in 65 cases (83.3%) and subtotal resection in nine cases. In four cases a biopsy was performed only. The overall postoperative neurological state was improved or unchanged in 51 patients (65.4%) and worsened in 27 patients (34.6%). A favorable functional outcome was observed in 94.1% of patients with vascular tumors, in 61.3% of patients with low-grade neuroepithelial tumors and in 53.3% of patients with malignant tumors. CONCLUSIONS: The strongest predicting factor of functional outcome was the preoperative neurological condition beyond the histological differentiation of the IMSCT. Although there was no outcome difference with respect to the age and tumor extension, thoracically located IMSCTs proved to harbor an increased risk of postoperative surgical morbidity.

The supraorbital keyhole approach via an eyebrow incision for resection of tumors around the sella and the anterior skull base.

OBJECTIVE: This study evaluates the technique, indications, advantages and limitations of the minimal invasive supraorbital keyhole approach via an eyebrow skin incision for resection of tumors around the sella and the anterior skull base. METHODS AND RESULTS: In 9 patients (5 males, 4 females) different tumors (6 meningiomas, 1 craniopharyngioma, 1 Rathke's cleft cyst and 1 hypophysitis) with a maximum diameter of 30 millimeters were resected via a small eyebrow incision and a supraorbital keyhole craniotomy. Details of the operative procedure include the use of a high-speed drill, a microsaw, bayonet-shaped instruments, careful microsurgical dissection, the use of a neuroendoscope and miniplates for closure. In all patients complete tumor removal was achieved. Mean duration of surgery was 01 h 51 min and mean hospital stay was 8.9 days. There were no significant postoperative complications. Clinical examination and MR imaging after a mean follow-up of 313 days revealed no tumor recurrence and a very satisfying overall functional and cosmetic result in all patients. CONCLUSION: The eyebrow incision supraorbital keyhole approach proved to be safe, effective and time-sparing. The authors recommend this approach for resection of small tumors around the sella and the anterior skull base in selected cases as a valuable alternative to standard skull base approaches.

Observations on intraoperative monitoring of visual pathways using steady-state visual evoked potentials.

BACKGROUND AND OBJECTIVE: Former studies revealed conflicting information on the usefulness of intraoperative monitoring of visual evoked potentials. This study was designed to evaluate the characteristics of visual evoked potential recording in surgically anaesthetized patients using the modality of steady-state visual evoked potentials. METHODS: In 30 cases with non-cranial surgery steady-state visual evoked potentials were recorded in the awake and surgically anaesthetized patient using total intravenous anaesthesia. For stimulation, goggles with red light-emitting diodes at a frequency of 8.5 Hz were used. A two-channel recording with silver cup electrodes at Oz to Fz and Oz to earlobe was used. All traces were analysed for the presence of the characteristically sinusoidal waveform and amplitudes and latencies of the main peaks were measured. RESULTS: Recordings during surgery demonstrated a minor latency prolongation of 16% and a more pronounced amplitude attenuation of 67% compared to the recordings in the awake patients. These differences were statistically significant (paired t-test, P < 0.001). In surgically anaesthetized patients steady-state visual evoked potentials showed a relatively high intra- and interindividual variability. In four of 30 patients completely stable recordings were obtained, whereas in 14 patients identifiable waves were recordable in only less than 50% of the intraoperative traces. Of the total 1360 traces recorded intraoperatively clearly identifiable steady-state visual evoked potentials patterns were present in 56% of the traces. There was no correlation between the magnitude of the evoked potential amplitude and its stability in intraoperative recordings. CONCLUSIONS: We conclude from this study, that steady-state visual evoked potential recordings in the surgically anaesthetized patient appeared to be more stable compared to our earlier findings using transient visual evoked potentials. However, further efforts are necessary to improve the stability of the recordings during surgery and thus allow for a more reliable intraoperative monitoring of visual pathways in routine clinical practice.

Does intraoperative aneurysm rupture influence outcome? Analysis of 169 patients.

OBJECTIVES: The aim of this study was to evaluate the prognostic value of intraoperative aneurysm rupture (IAR) in patients with subarachnoid hemorrhage (SAH) undergoing surgery for cerebral aneurysms. PATIENTS AND METHODS: Between July 1997 and April 2000, 292 consecutive patients were admitted to our institution with SAH due to ruptured intracranial aneurysms. Of these, 169 patients were treated surgically according to standard microsurgical procedures and were included in this study. Mean age was 47 years. Initial clinical state was graded according to the classification of Hunt and Hess (HH). Outcome was classified according to the Glasgow Outcome Scale as favorable (grades IV and V) and unfavorable (grades I-III). Outcome of patients with intraoperative ruptured and non-ruptured aneurysms was analyzed in correlation to the preoperative clinical state and with respect to the time of surgery and to aneurysm localization. RESULTS: Different rupture rates were observed with respect to the localization of the aneurysm: anterior circulation (n=69) 39.1%, middle cerebral artery (n=46) 34.8%, internal carotid artery (n=48) 31.2%, and posterior circulation (n=6) 16.7%. Patients with HH-grades I-III showed a favorable outcome in 72.2% (61 of 84 patients) without intraoperative rupture and in 71.7% (33 of 46 patients) with intraoperative aneurysm rupture. The corresponding values for patients with HH-grades IV/V were: favorable outcome in 34.6% (9 of 26 patients) and 23.1% (3 of 13 patients), respectively. Poor initial clinical condition (HH IV and V) as well as the initial Fisher grades III and IV were strongly associated with poor clinical outcome. CONCLUSIONS: Intraoperative aneurysm rupture has no impact on the outcome, neither in patients with good initial condition nor for poor grades patients.

False negative findings in intraoperative SEP monitoring: analysis of 658 consecutive neurosurgical cases and review of published reports.

OBJECTIVES: To determine the sensitivity of intraoperative monitoring in neurosurgical operations using somatosensory evoked potentials and to identify reasons for false negative findings and possible settings with an increased risk for monitoring failure. METHODS: SEP monitoring of 658 neurosurgical operations was analysed. The target of monitoring was the function of a hemisphere in 251 cases, the brain stem in 198 cases, and the spinal cord in 209 cases. RESULTS: In 27 cases (4.1%), monitoring was classified as false negative. Further analysis showed that five of these patients had experienced delayed neurological damage. Among the remaining 22 false negative cases, 14 had a minor neurological deficit and eight had severe neurological damage. Overall sensitivity and negative predictive value of SEP monitoring was 79% and 96%, respectively. For the detection of severe neurological damage the corresponding figures were 91% and 98%. Sensitivity of monitoring varied depending on the target of monitoring and the type of lesion. Monitoring was less likely to detect neurological damage in surgery for infratentorial tumours with brain stem compression, small lesions of the motor cortex, and small vessel damage during aneurysm surgery. CONCLUSIONS: SEP monitoring has acceptable sensitivity for detecting neurological damage during different neurosurgical procedures. Distinct settings with an increased risk of monitoring failure can be identified. In these cases measures to enhance the sensitivity of monitoring should be considered.

Surgical removal of brain stem cavernous malformations: surgical indications, technical considerations, and results.

OBJECTIVES: This study was undertaken to review the indications for surgical treatment of brain stem cavernomas and to develop strategies to minimise the complications of surgery. PATIENTS AND RESULTS: Twelve patients underwent surgical resection of a brain stem cavernoma due to symptoms caused by one or more haemorrhages. Age ranged from 18 to 47 years (mean 29.2 years). Long term follow up (mean 3.7 years) included a complete neurological examination and annual MRI studies. The annual haemorrhage rate was 6.8 %/patient/year and a rate of 1.9 rehaemorrhages/patient/year was found. Surgery was performed under microsurgical conditions with endoscopic assistance, use of neuronavigation, and neurophysiological monitoring. Navigation proved to be reliable when applied in an early stage of operative procedure with minimal brain retraction. Endoscopy was a useful tool in some cases to confirm complete resection of the lesion and to ascertain haemostasis. Ten patients had a new neurological deficit in the early postoperative period, nine of these were transient. At the last follow up the neurological state was improved in five patients, unchanged in six, and worse in one compared with the preoperative conditions. The preoperative average Rankin score was 2.2 points and had improved at the last follow up by 0.6 points to 1.6 points. CONCLUSIONS: Symptomatic brain stem cavernomas should be considered for surgical treatment after the first bleeding. Careful selection of the optimal operative approach and a meticulous microsurgical technique are mandatory. The additional use of modern tools such as neuronavigation, endoscopic assistance, and monitoring can contribute to the safety of the procedure.

Recurrent neurovascular hypertension: MR findings before and after surgical treatments.

A case of recurrent brain stem edema after surgical vascular decompression in a patient with neurogenic hypertension is presented. The surgical treatment resulted in occlusion of the left vertebral artery, stable blood pressure values, and no recurrence of the brain stem edema. MR imaging and MR angiography are excellent methods with which to assess patients suspected of having neurovascular hypertension, both before and after surgical treatment.

Endovascular treatment of a giant aneurysm of the internal carotid artery in a child with visual loss: case report.

We report on a case of a giant aneurysm of the internal carotid artery in a 11-year old boy presenting with gradual unilateral visual loss, combined with slight headache and retro-orbital pain. Endovascular balloon occlusion of the internal carotid artery combined with monitoring of somatosensory evoked potentials was performed. Follow-up MR imaging six months after balloon occlusion revealed complete thrombosis and considerable retraction of the aneurysm. However, visual loss persisted, since therapy was initiated too late and optic nerve atrophy had already occurred. It is important to emphasize that visual disturbance should be considered as an emergency, and, although rare, aneurysms do occur in the pediatric population.

Osteoplastic laminotomy using titanium microplates for reconstruction of the laminar roof: a technical note.

A technique to reconstruct the posterior elements of the spinal canal in osteoplastic laminotomy is described. The use of titanium microplates allows a stable fixation of the laminar arch with optimal realignment of the lamina cut ends. The titanium implants are fully compatible with magnetic resonance imaging. The author's experience with thirty patients is reported. The method proved to be simple and effective with distinct advantages over conventional techniques.

[Interdisciplinary surgical therapy of tumors of the frontal skull base]. / Interdisziplinäre operative Therapie von Tumoren der frontalen Schädelbasis.

Most tumors of the anterior cranial base invade both the intra- and extracranial regions at the borderline of the cranial and facial skeleton. In surgical treatment of these lesions, combined craniofacial approaches are applied in accordance with the anatomical conditions. Surgery is performed by an interdisciplinary team of neurosurgeons and maxillofacial surgeons. To evaluate the effectiveness and the complications of this surgical concept, the data of 58 patients treated over a 10-year period were collected. In these patients, 60 operations were performed, including two operations for tumor recurrence. In 38 cases, complete tumor removal was achieved. One patient died in the early postoperative period because of pulmonary embolism. Significant neurological deficits occurred in three patients. In most cases, postoperative complications and functional disability were both due to intradural invasion of the tumor. Nevertheless, in the majority of the cases radical tumor removal is achieved with acceptable morbidity when microsurgical techniques are applied for the resection of the intradural tumor. Both the meticulous repair of dural defects and the reconstruction of the anterior cranial base and orbit contribute distinctly to a reduction in the rate of postoperative complications and to acceptable cosmetic results.

[Interdisciplinary surgical treatment of tumors of the anterior cranial base]. / Interdisziplinäre operative Therapie von Tumoren der frontalen Schädelbasis.

Most tumors of the anterior cranial base invade both the intra- and extracranial regions at the borderline of the cranial and facial skeleton. In surgical treatment of these lesions, combined craniofacial approaches are applied in accordance with the anatomical conditions. Surgery is performed by an interdisciplinary team of neurosurgeons and maxillofacial surgeons. To evaluate the effectiveness and the complications of this surgical concept, the data of 58 patients treated over a 10-year period were collected. In these patients, 60 operations were performed, including two operations for tumor recurrence. In 38 cases, complete tumor removal was achieved. One patient died in the early postoperative period because of pulmonary embolism. Significant neurological deficits occurred in three patients. In most cases, postoperative complications and functional disability were both due to intradural invasion of the tumor. Nevertheless, in the majority of the cases radical tumor removal is achieved with acceptable morbidity when microsurgical techniques are applied for the resection of the intradural tumor. Both the meticulous repair of dural defects and the reconstruction of the anterior cranial base and orbit contribute distinctly to a reduction in the rate of postoperative complications and to acceptable cosmetic results.

Operative treatment and prognosis of syringomyelia.

Twenty-two patients suffering from syringomyelia were treated operatively. Different shunt procedures were performed. Most often syringo-subarachnoid shunt (seven cases) and syringopleural shunt (eight cases) were used. Operative findings and complications were discussed. Postoperative improvement was observed in five patients, twelve were stable-unchanged, four showed further deterioration and one died. Operative treatment should be performed before gross neurological deficit is established.

Spondylectomy, microsurgical decompression and osteosynthesis in the treatment of complex disorders of the cervical spine.

In 44 patients with complex degenerative, traumatic, neoplastic and infectious disorders of the cervical spine an aggressive surgical approach was used, consisting of spondylectomy, radical microsurgical decompression and osteosynthesis. The patient group consisted of 23 patients with multisegmental cervical spondylosis, 9 patients with primary or metastatic malignant tumour disease spread along the cervical spine, 6 patients with complex cervical trauma and 6 patients with infection affecting one or more cervical segments. Considering the heterogeneity of the group of patients treated, a multitude of neurological symptoms and signs were present. Excruciating pain was the predominant symptom in 84% of the patients, followed by sensory and motor signs of varying degrees in 77% and 65% respectively. Involvement of the long tracts was present in 51%, gait disturbance in 49% and bladder disfunction in 28%. Considering the nature of the underlying disease, in the group with multisegmental cervical spondylosis (MSCS), advanced cervical myelopathy was the predominant clinical symptom, whereas in those patients with trauma, tumour or infection, pain was the leading symptom, followed by disturbed motor and/or sensory function. Altogether 59 vertebrae have been removed in the 44 patients. In 28 patients spondylectomy was performed at one level, in 15 patients at two levels and in one female tumour patient at three levels. In 34 patients an iliac crest bone graft was used and in 10 patients bone cement. Within the observation period, solid fusion was achieved in all patients. In one tumour patient screw loosening was demonstrable at follow-up, but the fusion remained stable. 2 patients with infectious disease required re-operation due to significant loosening of screws and plates. However, after re-stabilization solid fusion was achieved. Considering amelioration of specific pre-operative symptoms and signs, excruciating pain responded best to the stabilizing procedure, with improvement in over 90% of the patients, followed by improvement of sensory and motor deficits in 85% and 82% respectively. Improvement in pre-operative gait disturbance could be achieved in 81% of the patients, while disturbance of bladder function is less likely to improve after surgery with a positive response in only 58%. None of the patients became neurologically worse after surgery. With regard to the underlying disease, patients with MSCS and tumour had the best results with overall improvement in 62% and 75% respectively. While in patients with infection improvement could be achieved in 58%, improvement in trauma patients was demonstrable in only 34% while in 66% the pre-operative clinical status remained unchanged.(ABSTRACT TRUNCATED AT 400 WORDS)

[Death in a neurosurgical intensive care unit. Analysis of 109 deceased intensive care patients]. / Tod auf einer neurochirurgischen Intensivstation. Analyse von 109 verstorbenen Intensivstationspatienten.

A retrospective study was performed on 109 patients who died in the neurosurgical ICU. We investigated the problem of outcome prediction in relation to diagnosis, status at admission and several risk factors. We analysed the meaning of diagnostical and therapeutical treatment and compared the clinical diagnosis to the neuropathological findings.