[Show abstract][Hide abstract] ABSTRACT: We present an unusual case of cerebellar haemorrhage followed by tension pneumocephalus several days after thoracotomy for resection of a Pancoast tumour. The postoperative course of the 32-year-old patient was complicated by a cerebellar haemorrhage and hydrocephalus caused by compression of the fourth ventricle. Immediate surgical evacuation of the haemorrhage and placement of an external ventricular drain was performed. Respirator ventilation maintaining a continuous positive airway pressure was required. Following weaning and extubation the patient rapidly deteriorated and became comatose. A cranial CT scan revealed a dilated ventricular system filled with air, and air in the subarachnoid space. Recovery of consciousness was observed after aspiration of intracranial air through the ventricular drainage. Recurrent deterioration of consciousness after repeated air aspiration indicated rapid refilling of the ventricles with air. The patient underwent emergency surgical re-exploration of the thoracic resection cavity: dural lacerations of the cervico-thoracic nerve roots C8 and Th1 were identified. Subarachnoid-pleural fistula, cerebellar haemorrhage and tension pneumocephalus after discontinuation of continuous positive airway pressure respiration are unusual complications of thoracic surgery. We discuss the putative pathomechanisms and present a brief review of the literature.
[Show abstract][Hide abstract] ABSTRACT: The management of colloid cyst remains controversial, evaluation of the competing methods seems to be necessary. We report on our experience with colloid cysts in the last decade: ten were managed solely endoscopically, 10 were resected microsurgically (9 via a transcortical/transventricular, 1 via a transcallosal approach). The outcome in the endoscopic group was excellent in 9 cases and unsatisfying in 1 case (recurrence). In the microsurgical group we achieved a good outcome in 5 of 10 cases, a fair outcome in 4 cases and 1 lethal outcome (caused by pulmonary embolism). Complications in the endoscopic group: one intraoperative bleeding, 1 stitch granuloma, 1 mispuncture of the ventricle, and 1 meningitis. Complications in the microsurgical group: 1 subdural effusion, 1 flap infection, 1 mild hemiparesis, 1 transient impairment of consciousness and 1 pulmonary embolism. Mean operative time and length of hospitalization of the endoscopic group were clearly shorter than in the microsurgical group: 91 min versus 267 min time of surgery, 5.1 days versus 18.9 days of hospitalization. Complete resection was achieved in 8 of 10 cases of microsurgery, and in 3 of 10 cases in endoscopy. Endoscopic management results in lower costs and superior patients' comfort. The reduced number of total resections in the endoscopic group may lead to a higher recurrence rate in long-term follow-up, which might be a serious disadvantage of endoscopy. However, more experience in the endoscopic techniques may result in a higher rate of total resection of colloid cysts.
[Show abstract][Hide abstract] ABSTRACT: The syndrome of haemolysis, elevated liver enzymes and low platelets (HELLP syndrome) is a life threatening, severe complication of pre-eclampsia with typical laboratory findings. An unusual case of a 36-year-old woman with HELLP syndrome and the initial complication of intracerebral haemorrhage is presented. The diagnosis of HELLP syndrome was confirmed by elevated liver enzymes, low platelets, increased total bilirubin and increased lactate dehydrogenase. The intracranial haematoma was removed with good neurological recovery ensuing. However, this case was complicated by cerebral vasospasm on the eleventh day, confirmed by cerebral angiography and computer tomographic findings. The patient died from brain swelling. Possible vasospam should be considered during the treatment of patients with HELLP syndrome.
[Show abstract][Hide abstract] ABSTRACT: Two cases of dural arteriovenous malformation (AVM) at the base of the anterior cranial fossa are described. In both cases an intracerebral hematoma following the rupture of the AVM was the first indication of the disease. In one case, the malformation was supplied both by the anterior ethmoidal artery and frontopolar artery draining into the superior sagittal sinus. In the second case, the right anterior ethmoidal artery with draining veins into the superior sagittal sinus and sphenoparietal sinus was the feeding vessel. Surgical evacuation of the hematoma and excision of the malformation was performed on both patients. The typical clinical signs and radiological findings are described. A review of the pertinent literature is given.
[Show abstract][Hide abstract] ABSTRACT: The case of a 17-year-old male with hydrocephalus caused by aqueductal obstruction is presented. A ventriculo-peritoneal shunt was implanted and later removed due to an infection. In the clinical follow-up no deterioration was observed. No further surgery was necessary. The repeat-MRI showed spontaneous resolution of the hydrocephalus with a normal aqueduct.
[Show abstract][Hide abstract] ABSTRACT: During a six-year (1986-1992) 334 patients with subarachnoid hemorrhage (SAH) were admitted to the Department of Neurosurgery. Medical University of Lübeck, Germany. In 281 patients the SAH was caused by rupture of an intracranial arterial aneurysm, verified by angiography, postmortem examination, or at emergency operation without angiography. In 67 (23.8%) of the 281 aneurysmal SAH patients the initial computerized tomography (CT) demonstrated an intracerebral hematoma (ICH). An ICH localized in the temporal lobe due to the rupture of a middle cerebral artery (MCA) aneurysm was found in 47 patients (70.2%). Forty-three patients were considered for surgery with a surgical mortality of 8 (18.6%). In the group of 19 ICH patients not operated upon, 16 individuals died (84.2%). We therefore advocate active surgical management of ICH patients: hematoma evacuation and aneurysm clipping at the same operation. Emergency surgery in younger patients (grade V) with temporal ICH suggesting the rupture of a MCA or internal carotid artery (ICA) aneurysm can be done without angiography.
[Show abstract][Hide abstract] ABSTRACT: Intracranial lesions may compromise structures critical for motor performance, and mapping of the cortex, especially of the motor hand area, is important to reduce postoperative morbidity. We investigated nine patients with parietal lobe tumours and used functional MRI sensitized to changes in blood oxygenation to define the different motor areas, especially the primary sensorimotor cortex, in relation to the localization of the tumour. Activation was determined by pixel-by-pixel correlation of the signal intensity time course with a reference waveform equivalent to the stimulus protocol. All subjects showed significant activation of the primary sensorimotor cortex while performing a finger opposition task with the affected and unaffected side. In five patients the finger opposition task additionally activated the ipsilateral sensorimotor cortex and the supplementary motor area (SMA). Extension and flexion of the foot, additionally performed in two patients, also activated the sensorimotor cortex, in one case within the perifocal oedema of the tumour. Tumour localization near the central sulcus induced displacement of the sensorimotor cortex as compared to the unaffected side in all patients with a relevant mass effect. The results of our study demonstrate that functional MRI at 1.5 T with a clinically used tomograph can reproducibly localize critical brain regions in patients with intracranial lesions.
[Show abstract][Hide abstract] ABSTRACT: Acute subdural haematoma (SDH) secondary to a ruptured intracranial aneurysm is a rare event. Out of a total of 292 patients with a verified aneurysm (period 1986-1992) in five cases SDH was the diagnosis on CT-evaluation. One patient was in such a bad condition that no treatment was indicated. The remaining four patients were operated on: craniotomy and haematoma evacuation in two cases, craniotomy for haematoma evacuation and aneurysm clipping in the other two cases. Two patients died and two achieved a good outcome.
[Show abstract][Hide abstract] ABSTRACT: The attitude concerning early clipping of aneurysms or generally aneurysm surgery in poor grade patients is controversial. There is no discussion about the space-occupying haematomas that must be removed urgently even in grade V patients if they have been admitted immediately after the acute event. Several patients in grade IV or V following a pure subarachnoid haemorrhage, can be improved by external ventricular drainage and thereafter their aneurysm operated upon with a better chance. Intelligible, the frequency of shunts needed is higher in poor than in good grade patients. Nevertheless, it can be reduced if the pressure, against what CSF is drained off, is kept on a higher level (about 20 cm H20) once the patient has stabilised. It also appears recommendable to operate upon aneurysms in patients who persist for several days in a condition no better than grade IV, rather than to assume an expectative attitude, for aneurysm rerupture mostly terminates the life of the patient, whereas clipping gives a change of recovery.
Neurological Research 03/1994; 16(1):45-8. · 1.44 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Aneurysm surgery began in Lübeck only in 1986 when the department was completely reorganized. Early operation in the good grade patients (I-III, according to Hunt and Hess) was performed. In every case we also discussed the feasibility of operating on the poor grade patients (Hunt and Hess IV and V). During a five-year period (1986-1991) a total of 277 SAH patients were admitted to the department. 109 (39%) patients arrived in a poor grade (Hunt and Hess IV or V), 12 of these patients died within hours of admission. 25 patients, who presented with a large intracerebral and/or subdural haematoma, were urgently operated upon by haematoma evacuation and aneurysm clipping. An external ventricular drainage was performed on 72 patients. Of the ventriculostomy group 33 patients improved and 27 were operated upon. In 17 of the 39 patients without improvement after CSF-drainage we decided to operate. Overall 69 patients were surgically treated (craniotomy, aneurysm clipping) and 40 were not. The mortality rate in the surgical cases was 16 (23%) compared with 30 (75%) without operation. It is concluded that poor grade aneurysm patients can achieve a better outcome with active treatment based on immediate ventriculostomy and optimal haemodynamic parameters after haematoma evacuation and early occlusion of the aneurysm.
[Show abstract][Hide abstract] ABSTRACT: Concerning hypothermia treatment, knowledge of time-temperature and of temperature distributions within tumor volumes is essential in order to obtain the maximal therapeutic effect. New techniques are being developed to overcome these difficulties. Two different heat sources, a contact Nd:YAG laser system and an automatically controlled high-frequency current system were investigated on 15 rabbits. Changes of the intracerebral temperature were registered at 4 different distances from the energy source. The intracerebral temperature was increased to 42.5 degrees C at a distance of 5 mm to the heat source and maintained at this level for a period of 60 min. The contact Nd:YAG laser system reached 42.5 degrees C at 3 W of output power. Using higher laser output power, brain tissue herniation (brain edema) through the burrhole was observed. The automatically controlled high-frequency current system reached 42.5 degrees C at 18.75 W of output current. A very small herniation of brain tissue could be observed using higher output current. Both heat sources presented an exponential decrease of the temperature profile depending on the distance. The tissue heat clearance was compensated for by intermittent laser or high-frequency current application. Both systems proved efficient for inducing hyperthermia as needed for antitumoral therapy.
[Show abstract][Hide abstract] ABSTRACT: The authors report on one case of an abscess at the pyramidal apex. The 52-year old male patient presented with pareses of the fifth and seventh cranial nerves and hypacusis on the right side. After diagnostic procedures (CT-scan, carotid angiography), a tumor at the apex of the right pyramid was expected. During surgery a large encapsulated mass was found containing pus. A bacterial agent could not be isolated. The abscess bordered on the mucosal lining of the sphenoid sinus and on the cells of mastoid bone. The starting point of an abscess at the pyramidal apex is most commonly an otitis media, most frequently caused by staphylococcus. Sterile abscesses are seen in almost 20%. Of differential diagnosis on has to keep in mind other space-occupying lesions especially epidermoid or dermoid cysts.
[Show abstract][Hide abstract] ABSTRACT: A 66-year-old woman presenting with pituitary insufficiency was operated on for an intrasellar tumor. Surprisingly, this tumor, at first suspected to be a hormone-inactive pituitary adenoma, consisted in fact of sarcoid granulomatous tissue in the pituitary gland as found histologically. The morphological picture as seen in the cranial computed tomography was identical with that of an adenoma. This possibility had not previously been considered, although there had been an extracerebral manifestation of the sarcoidosis in the left ovary.
[Show abstract][Hide abstract] ABSTRACT: Concerning hyperthermia treatment, knowledge of time-temperature and of temperature distributions within tumour volumes is essential in order to obtain the maximal therapeutic effect. New techniques are developed to overcome these difficulties. Two different heat sources, the contact Nd:YAG laser system and the automatically controlled high frequency current are investigated. In a defined volume of 1 cm3, the laser system reaches 45 degrees C after 1.8 s exposure with 15 W output power. The high frequency current reaches 45 degrees C with 48 s exposition with 18.75 W output current. Both heat sources present an exponential decrease of the temperature profile depending on the distance and prove efficient for inducing anti-tumoural hyperthermia. The tissue heat clearance is compensated for by intermittent laser and high frequency current application.
[Show abstract][Hide abstract] ABSTRACT: We present a case of a 63-year-old male patient who was admitted to our hospital due to an acute compression syndrome of the cauda equina. He had complained about a sciatica for at least one year. CT-diagnosis appeared to be negative, whereas a lumbar myelogram revealed a complete block at L2/3. Emergency surgery was performed, and an ependymoma of the filum terminale was removed into which it had bled massively. The case is compared to the literature findings. These relate ependymomas in the described region with acute onset more often to symptoms caused by subarachnoid bleeding. Mechanical and/or histopathological factors are discussed as the cause of acute bleeding. Spinal ependymomas represent a rare event compared to other neurosurgical diseases. Even more seldom are tumors of this kind causing an acute cauda equina compression syndrome.
[Show abstract][Hide abstract] ABSTRACT: The water jet cutting system allows transaction and dissection of biological structures with little bleeding. Structures of higher tissue rigidity remain unchanged while softer tissues are mechanically dissected. In brain tissue, all vessels larger than 20 microns are left intact after the passage of the jet stream with a pressure of up to 5 bar, and therefore vessels can be isolated selectively from the surrounding tissue. Oedema is present adjacent to the cut and no increase of temperature occurs.
British Journal of Neurosurgery 02/1989; 3(3):361-6. DOI:10.3109/02688698909002816 · 0.96 Impact Factor