A direct transnasal approach to the sphenoid sinus. Technical note.

The transsphenoidal route to the pituitary gland is well established in neurosurgical practice, and several approaches to the sphenoidal air sinus have been described. In this paper, the authors describe a technique that utilizes a direct route through the nasal cavity, thereby minimizing disruption of normal tissues.

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.

Compartmental analysis of cerebrospinal fluid transfer and absorption in simulated hydrocephalus.

A mathematical model of the cerebrospinal fluid (CSF) flow dynamics found in hydrocephalic infants with myelomeningocele lesions was constructed using criteria obtained from analogous clinical situations where 125I-labelled and 131I-labelled ortho-iodobenzoyl-amino-acetic acid (hippuran) had been employed to measure CSF flow dynamics. The quantitative results from this study allowed clinical data to be assessed and the importance of various CSF transfer mechanisms to be discussed. Our mathematical model indicates that the majority of radiopharmaceutical passes from the cerebral reservoir (the ventricles) into the blood. Experimental evidence indicates that the principal mechanism responsible for this movement is the bulk flow of CSF between its sites of production in the choroid plexus and absorption by the arachnoid villi.

Prediction of an extruded fragment in lumbar disc patients from clinical presentations.

To determine whether the presence of an extruded lumbar disc prolapse could be predicted from clinical symptoms, the authors compared the relative proportions of back and leg pain, with operative findings in a prospective observational study of 100 lumbar discectomy patients. All cases were assessed by an independent observer, blind to the knowledge of the operative findings. Of the 58 men and 42 women (mean age 42, range 19-75), 47 patients had a subligamentous disc protrusion and 53 had an extruded disc fragment. Of 27 patients who presented with leg pain only, 26 (96%) were found subsequently to have an extruded fragment. Patients with an extruded fragment had a significantly higher proportion of leg:back pain (median 99:1) than those with a subligamentous disc protrusion (median 75:25, P < 0.001). Patients with leg pain only and those with a marked predominance of leg pain over back pain have a high probability of harboring an extruded disc fragment.

Control of hydrocephalus by endoscopic choroid plexus coagulation--long-term results and complications.

Endoscopic choroid plexus coagulation has been used for the control of hydrocephalus regularly at this unit for the past 20 years. 156 of these operations have been performed on 116 patients and the aim of this study was to assess the rate of long-term control of hydrocephalus and the complications of the procedure. Data have so far been found for 98 patients with a median age at operation of 5 months (range 1 week-30 years). After a mean follow-up period of 10.5 years there were 32 (33%) patients continuing without a ventricular shunt. One patient developed papilloedema and required ventricular shunting 16 years after choroid plexus coagulation. There were no deaths resulting from operation. 5 patients developed post-operative meningitis and 3 patients had post-operative infections of implants (2 shunts and 1 reservoir). No cases of post-operative meningitis have occurred since vancomycin and gentamicin have been added to the solution used to perfuse the ventricles after operation (28 cases). Other complications included post-operative fits (2), respiratory arrest in a premature baby (10, low-pressure state (1), blocked or leaking external ventricular drain (4), drain displacement (4), subdural effusion (1) and per-operative minor ventricular bleeding forcing abandonment of the procedure (2).

Technique of fontanelle and persutural ventriculoscopy and endoscopic ventricular surgery in infants.

The author describes a new type of neurosurgical operating telescope which makes possible the foundation of endoneurosurgery. Illumination through a fibre-optic bundle and image transmission through a series of coated air lenses in glass are based on Hopkins optical systems. The telescope is 2.6 mm in external diameter. The operating sheath introduced around the telescope by means of split obturators which dilate the telescope track, enlarges the external diameter of the instrument to 4.5 mm. Up to four special instruments (electrode, aspirating cannula, accessory light, perfusing cannula, scissors) or a grasping forceps can be introduced through the instrument sheath. The instrument can be introduced, using a sharp trocar, through the fontanelle or lambdoid suture in infants and through a burr hole in children. It has been used for third ventriculoscopy and choroid plexus coagulation. The latter has been carried out successfully through the anterior fontanelle and the lambdoid suture, bilaterally in 2-4 stages. Complications - one meningitis - have been the exception.

The treatment of childhood hydrocephalus by choroid plexus coagulation and artificial cerebrospinal fluid perfusion.

The authors report their experience in the treatment of childhood hydrocephalus by endoscopic choroid plexus coagulation and post-operative ventricular perfusion with artificial CSF. The procedure was carried out on 23 children without mortality. In 12 cases (52%) the procedure was successful in controlling the hydrocephalus. The average follow-up was 2.3 years. Eleven cases (48%) required shunting which was done from 1 week to 13 months following the choroid plexus coagulation. As cure of the hydrocephalus was achieved in over half of the patients, the authors recommend the procedure as a first line treatment for childhood hydrocephalus.

Intracarotid phenoxybenzamine for cerebral arterial spasm.

Phenoxybenzamine was injected into the carotid artery of 23 patients after operations on their cerebral arterial aneurysms. Rapid improvement was seen in three cases with pronounced neurological disability. The other 20 were treated prophylactically in an attempt to prevent the onset of spasm. These results would appear to indicate that intracarotid phenoxybenzamine may be of value in the treatment of cerebral arterial spasm, provided that it is given before irreversible infarction of the brain has occurred. Until more is known about its action it would be best to give the drug only after operation.

Microdiscectomy.

Despite the introduction of microdiscectomy some fifteen years ago, the spread of this procedure amongst surgeons who operate on discs has been disappointingly slow. The overall impression of the impact which this operation has made on the surgery of lumbar discs is considerable and the authors recommend that this should now be the standard operation for disc sciatica, especially as the operation can now be performed as an outpatient procedure.

Intimal dissection following percutaneous transluminal carotid angioplasty for fibromuscular dysplasia.

Fibromuscular dysplasia (FMD) is an unusual form of segmental arteriopathy and may affect the internal carotid artery (ICA). We report a case of carotid FMD in which percutaneous transluminal angioplasty (PTA) was complicated by an intimal tear and required surgical exploration. PTA is a useful form of treatment, but there is a risk of intimal dissection. If this occurs, it may be necessary to excise the intimal flap surgically.

Objective and subjective memory impairment in pregnancy.

Pregnant subjects rated their memories as worse than normal and their ratings differed significantly from controls. Explicit memory tested by both recognition and recall was unimpaired. In contrast, implicit memory was significantly impaired in primigravidae. Impairment in implicit memory correlated with the subjective memory ratings. The dissociation of explicit and implicit memory is discussed.

Benign intracranial hypertension after pituitary surgery for Cushing's disease.

An 11 year old girl underwent successful transsphenoidal pituitary adenomectomy for pituitary-dependent Cushing's syndrome. Three months after operation, just after stopping glucocorticoid replacement therapy, she developed benign intracranial hypertension. This resolved when exogenous glucocorticoids were restarted but occurred again when they were later stopped. On restarting glucocorticoids again, this second episode of intracranial hypertension resolved. This complication may have been due to the large fall in endogenous cortisol production after removal of her adenoma and subsequent persistent mild endogenous hypocortisolism.

Advances in image-directed neurosurgery: preliminary experience with the ISG Viewing Wand compared with the Leksell G frame.

Because of the limited application of frame-based stereotaxy to general neurosurgical procedures, we have carried out a preliminary evaluation of the ISG Viewing Wand, a frameless image-directed surgical system that is based on the rapid reformat and accurate three-dimensional reconstruction capability of parallel processor-based computer technology. We have compared the first 36 cases carried out with the system in the Frenchay Neurosurgery Department with a retrospective analysis of the previous 36 cases carried out using the Leksell G frame. The stereotactic cases were completed over a period of 15 months, representing 2.8% of intracranial procedures. The wand cases were completed in 3 months, 13% of the intracranial practice during that time. The wand was used for 28 supratentorial craniotomies (76%), four infratentorial procedures (11%) and five biopsy procedures (13%). Conventional stereotaxy was not used for posterior fossa or skull base procedures. Supratentorial craniotomy was carried out in nine cases (25%), while the remaining 27 cases involved point source localization within the cranium (75%). The mean preparation time prior to surgery was 65 min for the stereotactic cases and 37 min for the wand cases. We therefore conclude that the indications for frame-based stereotaxy and Viewing Wand use are mutually exclusive. Leksell stereotaxy remains the method of choice for point source localization deep within the cranium. All other procedures requiring an image-directed minimally invasive surgical approach are more appropriately carried out using the Viewing Wand. The system has potential immediate application in supratentorial, skull base and infratentorial tumour surgery, vascular surgery, epilepsy surgery and upper cervical spine surgery.

Trophoblast membrane infusion for unexplained recurrent miscarriage.

A novel protocol is described which has been developed for immunotherapy in unexplained recurrent miscarriage. This is based on a single intravenous infusion with isolated placental trophoblast plasma membrane vesicle preparations. Clinical experience gained with this approach is described. A total of 16/21 (76%) patients who subsequently had pregnancies have now achieved a live birth or are currently pregnant at greater than 28 weeks gestation.