Outcome After Clipping of Unruptured Intracranial Aneurysms Depends on Caseload.

OBJECTIVE: Although most neurovascular centers currently have a coil first policy, the percentage of coiled versus clipped aneurysms, as well as treatment outcomes, varies strongly between these centers. This study evaluates the impact of an increase in clipping caseload on treatment outcome in a large single-center series. METHODS: All consecutive patients who underwent microsurgical clipping of unruptured intracranial aneurysms between January 2003 and April 2014 in our department were analyzed retrospectively. According to the change of the chairman in the neurosurgical department (1 September 2008) with a subsequent increase in the clipping volume, the entire cohort was divided into 2 groups with equal time intervals (historic and current cohorts). RESULTS: There were 94 clipped unruptured intracranial aneurysms in the historic cohort and 252 in the current cohort. Unfavorable outcome at 6 months postoperatively (defined as modified Rankin Score >2) was observed in 8 cases (8.5%) in the historic cohort and 7 cases (2.8%) in the current cohort (P < 0.0001). The surgical mortality decreased from 3.2% to 0%. Cerebral infarction on postoperative computed tomography scan was observed in 25 cases (26.6%) in the historic cohort and 19 cases (7.5%) in the current cohort (P < 0.0001). Within the current cohort, there was a progressive improvement of surgical outcome over the time. CONCLUSIONS: The improvement of the surgical outcome after increasing the clipping caseload underlines the importance of sufficient surgical volume for maintenance of competitive treatment results.

Predictive chromosomal clusters of synchronous and metachronous brain metastases in clear cell renal cell carcinoma.

Synchronous (early) and metachronous (late) brain metastasis (BM) events of sporadic clear cell renal cell carcinoma (ccRCC) (n = 148) were retrospectively analyzed using comparative genomic hybridization (CGH). Using oncogenetic tree models and cluster analyses, chromosomal imbalances related to recurrence-free survival until BM (RFS-BM) were analyzed. Losses at 9p and 9q appeared to be hallmarks of metachronous BM events, whereas an absence of detectable chromosomal changes at 3p was often associated with synchronous BM events. Correspondingly, k-means clustering showed that cluster 1 cases generally exhibited low copy number chromosomal changes that did not involve 3p. Cluster 2 cases had a high occurrence of -9p/-9q (94-98%) deletions, whereas cluster 3 cases had a higher frequency of copy number changes, including loss at chromosome 14 (80%). The higher number of synchronous cases in cluster 1 was also associated with a significantly shorter RFS-BM compared with clusters 2 and 3 (P = 0.02). Conversely, a significantly longer RFS-BM was observed for cluster 2 versus clusters 1 and 3 (P = 0.02). Taken together, these data suggest that metachronous BM events of ccRCC are characterized by loss of chromosome 9, whereas synchronous BM events may form independently of detectable genetic changes at chromosomes 9 and 3p.

Spontaneous cerebellar hemorrhage--experience with 57 surgically treated patients and review of the literature.

The treatment of spontaneous cerebellar hemorrhage is still discussed controversially. We analyzed a series of 57 patients who underwent surgical evacuation of a cerebellar hematoma at our department. Preoperative clinical and radiological parameters were assessed and correlated with the clinical outcome in order to identify factors with impact on outcome. The overall clinical outcome according to the Glasgow Outcome Scale at the last follow-up was good (GOS 4-5) in 27 patients (47%) and poor (GOS 2-3) in 16 patients (28%). Fourteen patients (25%) died. The initial neurological condition and the level of consciousness proved to be significant factors determining clinical outcome (p = 0.0032 and p = 0.0001, respectively). Among radiological parameters, brain stem compression and a tight posterior fossa solely showed to be predictive for clinical outcome (p = 0.0113 and p = 0.0167, respectively). Overall, our results emphasize the predictive impact of the initial neurological condition on clinical outcome confirming the grave outcome of patients in initially poor state as reported in previous studies. The hematoma size solely, in contrast to previous observations, showed not to be predictive for clinical outcome. Especially for the still disputed treatment of patients in good initial neurological condition, a suggestion can be derived from the present study. Based on the excellent outcome of patients with good initial clinical condition undergoing surgery due to secondary deterioration, we do not recommend preventive evacuation of a cerebellar hematoma in these patients.

Proliferation activity is significantly elevated in partially embolized cerebral arteriovenous malformations.

BACKGROUND: The natural history of cerebral arteriovenous malformations (AVMs) is yet to be determined. It has been shown that angiogenic factors are involved in the pathogenesis of AVMs, in particular in partially embolized lesions. This study was conducted to investigate the expression of angiogenic and proliferative factors in relation to different clinical conditions and treatment modalities. METHODS: Immunohistochemistry was performed for 145 consecutive cases of cerebral AVMs. The specimens were stained with antibodies against VEGF, bFGF, Ki 67, CD 34 and CD 31. Expression was correlated with clinical presentation (haemorrhage, seizures or other symptoms), AVM localization, size, eloquence and venous drainage, as well as with preoperative AVM embolization. RESULTS: Whereas no correlation was found between the expression of angiogenic factors and different clinical conditions, we observed a significantly increased proliferation activity as shown by Ki 67 expression in patients with intracerebral haemorrhage (p = 0.02) and in patients with preoperative embolization (p = 0.02). CONCLUSIONS: Increased proliferation activity in partially embolized AVMs supports a 'no-touch' strategy and clinical observation in high-risk AVMs and demands complete AVM elimination in treatable lesions.

AVM resection after radiation therapy--clinico-morphological features and microsurgical results.

A subgroup of patients initially treated by radiosurgery underwent surgical resection because of recurrent hemorrhage or neurological deterioration. In a retrospective study, we want to analyze the clinical features of these patients and evaluate the effect of microneurosurgery in such rare constellations. Moreover, we hope to find answers about failure of radiation therapy in these cases by correlation of radiobiological and histopathological data. Over a 16-year-period, eight patients with cerebral arteriovenous malformation (AVM) underwent surgical resection, who previously were treated by radiosurgery. The mean duration between radiation therapy and final resection was 7 years. Preoperative evaluation revealed Spetzler-Martin grade III (n=5) and IV (n=3) AVMs. Histological examination was achieved in all resected lesions. Mean neurological follow-up was 14 months. Indications for surgical resection were intracerebral hematoma, progressive neurological deficit, and epilepsy. In comparison to the initial angiographic study before radiation therapy, preoperative angiography revealed newly developed "en passant" feeding vessels and stenosis of the main venous drainage in some patients. The mean Rankin score for all patients was 2.75 before and 3.25 after surgical resection. Postoperatively, three patients (38%) developed neurological deterioration. Histological examination of the resected tissue revealed significant radiation-induced pathology in six patients. We did not see correlation between radiation doses and severity of histolopathological radiation-induced changes. Postoperative angiography confirmed total AVM resection in all patients. AVMs insufficiently treated by radiation bear an increased surgical risk. Often, angiographic studies revealed a more complicated morphology. Microsurgical resection was extremely challenging and led to unfavorable outcomes in many of the patients.

Decompressive laminoplasty in multisegmental cervical spondylotic myelopathy: bilateral cutting versus open-door technique.

PURPOSE: The aim of the study was to evaluate patients with multisegmental cervical spondylotic myelopathy (MCM) surgically treated via a dorsal approach. Two different laminoplasty techniques were compared by assessment of enlargement of the spinal canal and the neurological outcome. METHODS: Thirteen patients (mean age 49 years, 11 males) underwent decompressive laminoplasty over a 7-year period. The average duration of symptoms was 21 months. The pre- and postoperative degree of myelopathy was assessed by both the Nurick grading and the Japanese Orthopaedic Association myelopathy score (JOA score). Preoperatively, the mean Nurick grade was 3.1 and the mean JOA score was 11. Two different techniques of expansive laminoplasty were used. Six patients underwent a bilateral cutting (BL) technique with retropositioning of the laminae and bilateral mini-plating (BL group). Seven patients were operated on by simple open-door (OD) laminoplasty with unilateral mini-plating (OD group). Postoperatively, CT scans were obtained for all patients to measure the sagittal diameter of the spinal canal. The mean clinical and radiological follow-up was 33 months. RESULTS: Four to five laminae were involved in all patients.The mean operation time was 180 min. Complications occurred in two patients of BL group, with immediate postoperative neurological deterioration due to ventral displacement of the laminae. Overall, the average sagittal diameter (SD) of the spinal canal increased from 9.2 +/- 1.3 mm to 12.4 +/- 1.3 mm after surgery. The average enlargement of SD was significantly higher for the OD group (p < 0.0075 ). In total, the improvement rate was 38% according to the Nurick grading and 69% according to the JOA score. For the OD group, improvement rates were 57% (Nurick) and 71% (JOA). CONCLUSIONS: Decompressive laminoplasty is comparable with anterior surgery in neurological outcome. The OD technique seems to be superior to our BL technique regarding both the enlargement of SD and complication rate.

Anterior clinoidal meningiomas: functional outcome after microsurgical resection in a consecutive series of 106 patients. Clinical article.

OBJECT: In this study, the authors' goal was to analyze a series of patients treated microsurgically for an anterior clinoid process (ACP) meningioma in regard to long-term functional outcome. METHODS: The authors retrospectively analyzed clinical data in a consecutive series of 106 patients who underwent microsurgical treatment for an ACP meningioma at 2 neurosurgical institutions between 1987 and 2005. The main presenting symptoms of the 84 female and 22 male patients (mean age 56 years) were visual impairment in 54% and headache in 28%. Physical examination revealed decreased visual acuity in 49% and a visual field deficit in 26%. Tumors were primarily resected via a pterional approach. Meningioma extensions invading the cavernous sinus, present in 29% of the patients, were not removed. Complete tumor resection (Simpson Grade I and II) was achieved in 59% of the cases. RESULTS: Postoperatively, visual acuity improved in 40%, was unchanged in 46%, and deteriorated in 14%. A new oculomotor palsy was observed in 8 patients (8%). Clinical and MR imaging data were available in 95 patients for a mean postsurgical period of 6.9 years (1.5-18 years) and revealed tumor recurrence in 10% and tumor progression after subtotal resection in 38%. Clinical deterioration on long-term follow-up consisting primarily of ophthalmological deficits was observed in 14% of the cases. CONCLUSIONS: Acceptable functional results can be achieved after microsurgical resection of ACP meningiomas; however, long-term treatment remains challenging due to a high tumor recurrence and progression rate.

Spinal meningiomas: critical review of 131 surgically treated patients.

This study was undertaken to analyze the functional outcome of surgically treated spinal meningiomas and to determine factors for surgical morbidity. Between January 1990 and December 2006 a total of 131 patients underwent surgical resection of a spinal menigioma. There were 114 (87%) female and 17 (13%) male patients. Age ranged from 17 to 88 years (mean 69 years). The mean follow-up period was 61 months (range 1-116 months) including a complete neurological examination and postoperative MRI studies. The pre- and postoperative neurological state was graded according to the Frankel Scale. Surgery was performed under standard microsurgical conditions with neurophysiological monitoring. In 73% the lesion was located in the thoracic region, in 16% in the cervical region, in 5% at the cervico-thoracic junction, in 4.5% at the thoraco-lumbar junction and in 1.5% in the lumbar region. Surgical resection was complete in 127 patients (97%) and incomplete in 4 patients (3%). At the last follow-up the neurological state was improved or unchanged in 126 patients (96.2%) and worse in 4 patients (3%). Permanent operative morbidity and mortality rates were 3 and 0.8%, respectively. Extensive tumour calcification proved to be a significant factor for surgical morbidity (P < 0.0001). Radical resection of spinal meningiomas can be performed with good functional results. Extensive tumor calcification, especially in elderly patients proved to harbor an increased risk for surgical morbidity.

Meningiomas of the falcotentorial junction: selection of the surgical approach according to the tumor type.

BACKGROUND: We retrospectively analyzed a series of patients harboring a FT meningioma with regard to clinical presentation, surgical technique, and follow-up results. METHODS: Clinical data in a consecutive series of 13 patients treated for a meningioma of the FT junction were retrospectively reviewed. Tumors were classified into 4 types according to their dural origin and tumor extent as depicted from preoperative MRI. RESULTS: Main presenting symptom in 9 women and 4 men (mean age, 56 years) was headache (69%) and gait disturbance (54%). Clinical examination revealed gait ataxia in 62% of the patients. The tumor displaced the vein of Galen inferiorly in 6 patients, superiorly in 2, and medially in 5 cases. The main surgical approach to the meningioma was via an occipital interhemispheric route (10 patients). Additional resection of the falx and/or incision of the tentorium was performed in 6 cases each. A complete resection (Simpson grade 1 and 2) was achieved in 85% of patients. Permanent surgical morbidity was 23%. One tumor recurrence in an atypical meningioma was observed after the mean follow-up period of 6.2 years (range, 1-14 years) with clinical and MRI examination and had to be reoperated. Eighty-five percent of the patients regained full daily activity on follow-up. CONCLUSIONS: The surgical approach should be tailored to the dural origin and extent of the tumor as depicted from preoperative MRI. Preservation of the straight sinus and Galenic venous system is recommended.

The impact of subarachnoid hemorrhage on regional cerebral blood flow and large-vessel diameter in the canine model of chronic vasospasm.

OBJECTIVE: The aim of this study was to correlate changes in regional cerebral blood flow (rCBF) to the degree of cerebral vasospasm in the canine two-hemorrhage model of subarachnoid hemorrhage (SAH). METHODS: SAH was induced in 13 adult beagle dogs using the two-hemorrhage model. Eleven beagle dogs served as controls. Angiography of the basilar artery and measurements of rCBF with colored microspheres were performed on days 1 and 8. Diameter of the basilar artery was calculated at equidistant points from the angiogram. RESULTS: In controls, basilar artery diameter (mm) and rCBF (mL/min/g) were equal on days 1 and 8. In the SAH group, basilar artery diameter decreased significantly (1.27 +/- 0.17 [mean +/- SD]-0.84 +/- 0.15 mm). rCBF decreased significantly (P < .05) in the cerebrum (1.69 +/- 0.54 [mean +/- SD]-1.06 +/- 0.45 mL/min/g), cerebellum (1.18 +/- 0.40-0.80 +/- 0.32 mL/min/g), and brain stem (0.81 +/- 0.33-0.51 +/- 0.21 mL/min/g). However, decrements in CBF were not correlated to the reduction in vessel caliber in the corresponding vascular territory. CONCLUSION: Induced SAH in the canine model produces a significant impairment in rCBF irrespective of the degree of vasospasm of large cerebral vessels. The findings support the presumptive role of the microvasculature in regard to delayed cerebral ischemia after SAH.

Analysis of intrathecal interleukin-6 as a potential predictive factor for vasospasm in subarachnoid hemorrhage.

OBJECTIVE: Inflammatory response seems to be one of the relevant pathophysiological aspects for developing vasospasm in subarachnoid hemorrhage. The probable diagnostic value of intrathecal proinflammatory markers is still unclear and is assessed in this study. METHODS: We analyzed daily clinical data and laboratory tests of the cerebrospinal fluid (CSF) of 64 patients with mostly poor-grade subarachnoid hemorrhage during a period of 14 days. Special attention was given to the relationship between the development of vasospasm and the time course of the intrathecal interleukin (IL)-6 concentrations in CSF (IL-6CSF). The potential power of IL-6CSF for predicting vasospasm was studied. RESULTS: Vasospasm developed in 28.1% of the patients, with a mean onset of 6.4 days after bleeding, and was detected by conventional methods. Patients with vasospasm demonstrated statistically significant higher median values of IL-6CSF on Days 4 and 5 (P < 0.05). Most importantly, the increase of IL-6CSF preceded the conventional signs of vasospasm. A cut-off value of IL-6CSF of at least 2000 pg/ml on Day 4 yielded an 11.72-fold higher relative risk (95% confidence interval, 2.93-46.60) of developing vasospasm, predicting vasospasm with a sensitivity of 88.9% and a specificity of 78.3%. We found a statistically significant correlation between IL-6CSF and delayed cerebral ischemia for Day 7 (P = 0.03). However, there was no correlation with IL-6CSF on any other day and outcome. CONCLUSION: IL-6CSF seems to be a reliable early marker for predicting vasospasm after subarachnoid hemorrhage on Days 4 and 5 before clinical onset.

Dural involvement in primary extradural meningiomas of the cranial vault.

OBJECT: The authors retrospectively analyzed a consecutive series of patients with cranial vault primary extradural meningioma (PEM), with particular regard to the tumor's dural involvement. The pertinent literature was reviewed. METHODS: Clinical data were retrospectively obtained in a consecutive series of 16 patients treated for a PEM at two institutions between 1992 and 2004. The authors created a classification system based on dural involvement of the tumors. Nine women and six men (mean age 55 years) presented with a painless, slowly progressive swelling. Preoperative magnetic resonance (MR) imaging revealed dural enhancement at the site of tumor in 11 patients. On surgical inspection, the tumor infiltrated the dura in all but three patients. Histological examination of tissue samples demonstrated tumor infiltration of the dura in all 14 patients in whom the dura had been resected. Three recurrent tumors were observed on follow-up examination during a mean period of 5.8 years (range 1.5-13 years) and required extirpation. In addition to one patient in whom there was histological evidence of malignancy, the other two cases involved two patients in whom no apparent dural involvement was observed during the first surgery. In a review of the literature, the authors found that histological examination showed dural involvement in 22%; the dura was not histologically evaluated in the remaining patients (78%). Postoperative follow-up data exceeding 2 years were only provided in two of the reported cases. CONCLUSIONS: Tumor infiltration of the dura should be assumed in PEMs of the cranial vault, and resection of the dura at the site of craniotomy is recommended to prevent tumor recurrence.

Tuberculum sellae meningiomas: functional outcome in a consecutive series treated microsurgically.

OBJECTIVE: The objective of this study was to analyze a series of patients harboring a tuberculum sellae meningioma with regard to clinical presentation and long-term functional outcome. METHODS: Data in a consecutive series of 62 patients harboring a tuberculum sellae meningioma treated microsurgically between 1990 and 2003 were retrospectively reviewed. RESULTS: The mean age of the 46 women and 16 men enrolled in the study was 53 years (range = 29-81 years). The presenting symptom was visual compromise in 87.1% of the patients, and examination revealed decreased visual acuity in 79% and impaired visual fields in 64.5% of the patients. In addition, 14.5% of the patients had preoperative hormonal abnormalities. Simpson grades I and II resections, usually via a pterional approach, were achieved in 90.3% of the patients. Postoperatively, vision improved in 53.2%, remained unchanged in 29.8%, and deteriorated in 17.0% of the patients. The intraoperative finding predicting an unfavorable visual outcome was a thin atrophic optic nerve, encasement of the nerve, or tumor adhesion to its undersurface. Of the patients, 12.9% required permanent postoperative hormonal replacement. After a mean follow-up period of 6.0 years (range = 18 months-14 years), 88.7% of the patients resumed normal life activity and 2 recurrent tumors were observed (3.2%) and reoperated. CONCLUSIONS: Preoperative magnetic resonance imaging provides reliable information with regard to dislocation of critical vascular structures. However, the relationship between optic nerves and tumors (eg, adhesion and encasement) affected postoperative results and can only be fully appreciated during microsurgery. Visual outcome may be improved by preserving the microvasculature supplying the optic apparatus.

Vascular endothelial growth factor plasma levels are significantly elevated in patients with cerebral arteriovenous malformations.

BACKGROUND: Since growth and de novo generation of cerebrovascular malformations were demonstrated, a strictly congenital model cannot be further supported as unique factor in the pathogenesis of cerebral arteriovenous malformations (AVMs). Vascular endothelial growth factor (VEGF) has previously been demonstrated to be highly expressed in AVMs by immunohistochemical methods. However, systemic VEGF levels have not been analysed previously. This study aimed to investigate VEGF plasma concentrations as a possible plasma marker for neovascularization in patients with cerebral AVMs compared to healthy controls. METHODS: The study included 17 patients with cerebral AVMs and 40 healthy controls. VEGF plasma concentrations were measured by a specific enzyme immuno-assay. RESULTS: VEGF plasma concentrations were significantly higher in patients with cerebral AVMs (mean 140.9 pg/ml, SD 148.5 pg/ml and median 63.0 pg/ml) compared to a healthy control group (mean 44.7 pg/ml, SD 36.4 pg/ml and median 35.0 pg/ml), p = 0.0003. CONCLUSIONS: Our findings suggest that VEGF plasma concentrations might play a role in the pathogenesis of cerebral AVMs. Further studies are necessary and would contribute to an improved understanding of the pathogenesis of cerebral AVMs.

Fusion of the cerebellar hemispheres ventral to the brainstem: a rare hindbrain-related malformation.

INTRODUCTION: New variations of cerebellar malformations are being increasingly recognized using modern neuroimaging techniques. Until now only dorsal cerebellar fusion syndromes, such as the rhombencephalosynapsis and its variations have been recognized. CASE REPORT: We report on a 17-month-old male infant presenting with an exceptional hindbrain related malformation characterized by midline fusion of the cerebellar hemispheres ventral to the brainstem and causing symptoms due to brainstem compression. DISCUSSION AND CONCLUSION: A more detailed understanding of the cerebellar embryogenesis is required to unravel the underlying mechanisms leading to this type of cerebellar malformation, which cannot easily be integrated into the common classification systems. Both the morphological features and the clinical presentation are different from those of other cerebellar structural abnormalities. If this type of congenital malformation is detected more frequently in the future, it seems reasonable that it should be added to the list of cerebellar malformations as a distinct type.

VEGF plasma levels in non-ruptured intracranial aneurysms.

Aneurysm growth appears to be associated with an increased risk of rupture. Therefore, it may be of interest to identify mechanisms contributing to aneurysm growth. Angiogenic factors, particularly vascular endothelial growth factor (VEGF), appear to play an important role in the pathogenesis and growth of cerebrovascular malformations. We aimed to study systemic VEGF levels as a potential systemic marker in patients with non-ruptured intracranial aneurysms compared with healthy controls. Mean VEGF plasma concentrations were found to be increased in patients with non-ruptured intracranial aneurysms compared with healthy controls (85.2 pg/ml versus 44.1 pg/ml). This difference did not reach significance in the analyzed study cohort (p=0.05) but only when the analysis was restricted to male patients (p=0.04). Female patients and controls demonstrated significantly increased VEGF plasma levels only on correlation with age but not with the presence of aneurysms. Neither the presence of multiple aneurysms nor aneurysm location were correlated with VEGF levels. Although overall VEGF plasma difference was not statistically significant, we found significantly increased levels in male patients. Furthermore, we identified a distinct group of female patients with intracranial aneurysms who presented excessively increased VEGF plasma levels to an amount that was not observed in the controls. Further studies may clarify the relationship of aneurysm growth and VEGF.

Foramen magnum meningiomas: clinical outcome after microsurgical resection via a posterolateral suboccipital retrocondylar approach.

OBJECTIVE: We analyzed a consecutive series of patients operated for a foramen magnum (FM) meningioma located on the ventral aspect of the medulla oblongata via a posterolateral suboccipital retrocondylar approach with regard to long-term surgical outcome. METHODS: Clinical data in a consecutive series of 25 patients experiencing a meningioma attached to dura of the anterior or anterolateral FM rim were retrospectively reviewed. RESULTS: The most common symptoms of the 19 women and six men (mean age, 59.2 yr) was cervico-occipital pain (72%) and gait disturbance (32%). Clinical examination revealed gait ataxia in 48% of the patients. As depicted from preoperative magnetic resonance imaging (MRI), dural attachment of the meningioma at the FM rim was anterior in 36% and anterolateral in 64% of cases. Tumor removal was accomplished via a posterolateral suboccipital retrocondylar approach in all patients. A Simpson Grade 2 resection was achieved in 96% of the patients. Permanent surgical morbidity and mortality rates were 8 and 4%, respectively. No tumor recurrence was observed after a mean follow-up period of 6.1 years (range, 1-14 yr) with clinical and MRI examination, and 80% of the patients have regained full daily activity. CONCLUSION: Anterior and anterolateral FM meningiomas that displace the medulla/spinal cord can be safely and completely resected via a posterolateral suboccipital retrocondylar approach. A tumor remnant should be left on critical neurovascular structures in cases with poor arachnoid dissection planes.

Functional magnetic resonance imaging in anesthetized patients: a relevant step toward real-time intraoperative functional neuroimaging.

OBJECTIVE: The introduction of intraoperative 1.5-T magnetic resonance imaging may provide up-to-date functional information in the surgical environment. However, feasible passive paradigms that allow the examination of anesthetized patients will be a precondition for intraoperative functional magnetic resonance imaging (fMRI). The aim of this study is to evaluate the feasibility of a recently developed passive fMRI paradigm for functional neuroimaging in anesthetized patients. METHODS: We investigated four anesthetized patients with intracranial pathological conditions not related to the sensorimotor cortex. All patients had been anesthetized with standard total intravenous anesthesia for more than 24 hours before the fMRI scan. Anesthesia and monitoring were sustained during the scanning procedure. A simultaneous electrical stimulation of the median and tibial nerves was applied to elicit a cortical activation using a custom-designed magnetoelectrically shielded conductor. Statistical evaluation using Statistical Parametric Mapping software (Wellcome Department of Imaging Neuroscience, University College, London, England) and the Talairach Daemon Client (Version 1.1; Research Imaging Center, University of Texas Health Science Center, San Antonio, TX) followed. RESULTS: Three of four patients showed a good activation of the sensorimotor cortex under anesthesia. In one patient, no significant activation was observed, presumably as a result of increased body impedance because of severe edema. Standard dosages of the narcotics did not influence the cortical response; however, stimulation intensity had to be increased compared with awake patients. We did not detect relevant interferences with magnetic resonance imaging arising from the technical setup. CONCLUSION: The method presented proved to be a feasible paradigm for fMRI evaluation of the sensorimotor cortex in anesthetized patients and thus forms a relevant step toward real intraoperative functional neuroimaging.

Spheno-orbital meningiomas: interdisciplinary surgical approach, resectability and long-term results.

OBJECTIVE: To describe the interdisciplinary surgical approach in spheno-orbital meningiomas and to evaluate the operative results regarding resectability and functional outcome. PATIENTS AND METHODS: A series of 16 patients underwent surgical resection of spheno-orbital meningiomas followed by bony reconstruction. Four patients presented with a recurrent meningioma and had undergone surgical resection previously. Radical tumour removal was attempted in all cases, although no aggressive effort was made to remove tumour tissue infiltrating the cavernous sinus or soft tissues deep in the orbit to avoid severe functional disturbances. All patients but one were female (mean age 53 years). Mean follow-up period was 68 months (range 4-155 months). RESULTS: The leading symptom was proptosis in 14 patients, accompanied in 7 cases by progressive visual impairment. Surgical resection was thought to have been complete in 11 patients (69%) and incomplete in 5 (31%). Residual tumour was deliberately left when there was infiltration of the cavernous sinus (n = 4), the pterygopalatine fossa (n = 2) and/or the deep intraorbital soft tissues (n = 1). Tumour recurrence was observed in 9 patients, among whom were 6 patients with an initially "completely" resected meningioma. Eight patients underwent re-operation. Complete resection was achieved in 3 of these latter patients with an isolated exclusively intraorbital tumour manifestation. CONCLUSION: By means of combined skull base approaches, spheno-orbital meningiomas are grossly resected totally with a long-term survival free of recurrence and an acceptable quality of life. In some cases, deliberate subtotal tumour resection is useful to avoid severe neurological damage with sufficient tumour control and a valuable progression-free survival.