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  • 1
    ISSN: 0942-0940
    Keywords: Chiasmal glioma ; pilocytic astrocytoma ; hypothalamus ; neurofibromatosis
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Summary The authors review the therapeutic results of 20 patients (aged 12 months to 30 years, mean age 9 years) with benign pilocytic astrocytoma of the chiasmatic/hypothalamic region, seen at the University Hospital Hamburg-Eppendorf between February 1980 and April 1993. Six patients suffered from neurofibromatosis 1 (NF-1). The patients were divided into two subgroups relative to tumour extension and growth patterns, as revealed by CT scans and/or MR imaging. Fourteen patients revealed a large globular suprasellar tumour extending into the hypothalamus and/or the anterior third ventricle (group A). A suprasellar tumour with optic tract involvement could be identified in six cases (group B). Subtotal (70–90%) resection was achieved in ten tumours (50%), the majority of which were of the large globular type. There were no deaths. Postoperative morbidity was comprised of visual and endocrine impairment in four patients and right hemiparesis and dysphasia in one patient. Radiation therapy was given in nine cases (45%). Three tumours (38%) were reduced in size by irradiation. Tumour progression was seen in seven patients (35%). The presence of young age and NF-1 were predictors of progressive disease in our series. Growth capacity was not related to the extent of cytoreductive surgery.
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  • 2
    ISSN: 0942-0940
    Keywords: Ethiblock ; AV fistulas ; coils
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Summary We present the results of a series of 105 patients with cerebral arteriovenous malformations (AVMs) who were treated by a combined protocol including endovascular occlusive measures and open surgical resection. 25 patients were treated only by surgical intervention, 72 patients underwent preoperative endovascular embolization and 8 patients were treated only by embolization, seven of which were only treated for palliation. After superselective angiography the vascular territories suitable for endovascular or microsurgical approach were defined, and in most cases these territories were complementary to each other. In 56 cases, only one embolization was necessary and due to an advantageous co-localization of the departments the whole combined endovascular/neurosurgical procedure was done in one anesthesia. If several endovascular sessions were necessary (16 patients), the resection was mostly carried out immediately after the last neuroradiological session in the same anesthesia with total time of such combined procedure now averaging about 7 hours. According to the proposed grading system by Spetzler we treated 25 grade 1, 24 grade 2, 40 grade 3, 11 grade 4, and 5 grade 5 lesions. The overall success rate defined as complete resection without additional permanent neurological deficit was 89.6% (87 out of 97 surgical cases). The benefits of such combined approach to cerebral AVMs become apparent in shortened and safer surgical procedures as well as in a low complication rate.
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  • 3
    ISSN: 0942-0940
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Summary Systematic review of the cerebral angiograms of 446 head trauma patients (1971–1978) revealed the presence of an arteriovenous (AV) fistula of the middle meningeal artery (MMA) in 8 cases (1.8%), the total number of angiographically demonstrable injuries of the MMA being 18 (4%). AV fistulae of the MMA may prevent formation of epidural haematoma, but they are frequently associated with so severe damage to skull and brain that prognosis is nevertheless grave. A close relationship between the tighter adherence of the dura to bone in older age and development of an AV fistula of the MMA following trauma to the skull may be presumed.
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  • 4
    ISSN: 0942-0940
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Summary For treatment of spasmodic torticollis (s.T.) microsurgical decompression of the intraspinal-intracranial portion of the accessory nerve (a.N.) has been performed in 11 patients with proved neurogenic lesions of the accessory nerve-dependent muscles. Neurogenic lesions were discovered by meticulous electromyographic (EMG) examination in 26 out of 32 patients with s.T. Based on the EMG findings the a.N. roots were exposed, mostly bilaterally. During operation we found in each case tight adhesions to adjacent structures, in particular the vertebral artery (v.A.), the posterior inferior cerebellar artery (PICA), and spinal arteries. Moreover, various nerve anastomoses were found between the upper dorsal cervical roots and the spinal a.N. roots. After neurovascular lysis and dissection of anastomoses, to C 1 in particular, the a.N. was protected with teflon-foam (Prosthex). Immediately after surgery torticollis had improved in all but one case. Further improvement was achieved by exercises. These first favourable results, and the fact that nerve decompression is less destructive than other surgical procedures in treatment of s.T., make us feel justified in recommending this procedure further to patients suffering from s.T. with proved neurogenic lesions.
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  • 5
    ISSN: 0942-0940
    Keywords: Spasmodic torticollis ; spinal accessory nerve root ; bilateral microsurgical lysis
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Summary In 1981 we reported about a new surgical procedure for the treatment of spasmodic torticollis (ST). 33 patients, who failed to respond to the available conservative treatment, underwent a bilateral microsurgical lysis (BML) of the spinal accessory nerve roots (SRAN). Anastomoses between SRAN and the dorsal roots of the first and second cervical nerve (DRC 1/DRC 2) were cut. DRC 1 and sometimes DRC 2 were divided bilaterally. Moreover, SRAN was freed of all adhesions and vascular contacts. Up to 60 months after surgery we have exellent results in 5(5), good results in 10(7) and improved symptoms in 12(8) patients. In 3(7) patients symptoms were unchanged, 2(1) patients deteriorated (patients self assessment is given in brackets). One patient died during hospitalisation. Comparing torticollis symptoms and the post-operative outcome it can be shown that patients with horizontal ST have the best results (21 out of 22). Bad results were obtained in patients with combined torticollis symptoms such as retrocollis, antecollis and the rotatory/ horizontal type (5 out of 9). These results support the hypothesis of a peripheral factor in the aetiology of horizontal ST. It is assumed that a unilateral disturbance of proprioceptive afferents for head control, which reach the CNS via anastomosis between DRC 1/DRC 2 and SRAN (in 94% of the cases) could be involved. This hypothesis is discussed with special regard to different anatomical findings in patients with ST and those revealed in a study on human cadavers without this disease.
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  • 6
    ISSN: 0942-0940
    Keywords: Subarachnoid haemorrhage ; ruptured cerebral aneurysms ; cerebral vasospasm ; nimodipine ; timing of surgery ; treatment mortality ; morbidity
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Summary In 1984, in connection with the introduction of the calcium antagonist nimodipine, a new strategy for the treatment of subarachnoid haemorrhage (SAH) due to ruptured aneurysm was developed in our hospital. With no rigid regard to “timing” all patients undergo surgery as soon as possible. The only exception being those in Hunt and Hess grades IV and V without space-occupying intracranial haemorrhage and those bearing aneurysms of the vertebrobasilar circulation that are difficult of access. As soon as the risk of rebleeding has been eliminated surgically an active therapy against the possible consequences of SAH—cerebral vasospasm and simultaneous disturbances of autoregulation—is started. It consists in lowering the increased intracranial pressure, raising of mean arterial pressure and improving of rheological properties of the blood in order to prevent delayed build-up of neurological deficit due to ischaemia. It goes without saying that calcium antagonists are given from the very beginning of the patient's treatment even before operation. The advantages of this therapeutic concept are demonstrated by two series of non-selected consecutive patient material. The first series (A; n=135) was treated between 1981 and 1984 before the change in treatment strategy, the second (B; n=183) from 1984 to 1986 after that change. The overall mortality in series A was 27%, that in series B 20%. Operative mortality could be reduced from 22% to 16% in patients having undergone early operation and from 6% to 2% in patients with late surgery. Development of permanent neurological deficits following early surgical intervention was seen in 4 out of 29 grade I–III patients (14%) in series A and in 5 out of 94 of such patients (5%) in series B.
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  • 7
    ISSN: 0942-0940
    Keywords: Keywords: Meningioma; suprasellar; meningioma surgery; angiography.
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Summary  Most of the previously published surgical series of suprasellar meningiomas have two disadvantages: (1) patients involved were treated within a relatively long time period, making analysis more difficult, (2) radiographic long term follow-up examinations with either CT- or MRI-scans were not performed. Both disadvantages were overcome in our retrospective clinical study, consisting of 50 consecutive patients with suprasellar meningiomas treated between 1982 and 1991. Radiological, ophthalmological, and neurological investigations were performed pre-operatively, postoperatively and at long term follow-up (mean: 5.7 years). A radiologically confirmed radical tumour removal could be achieved in 84% of patients. Both, the peri-operative mortality (2%) and serious operative morbidity (6%) were low. However, 12% of patients developed late onset epilepsy. At long term follow-up, visual function was improved in 67%, unchanged in 9% and worsened in 24%. In more than 50% of patients the vision showed recovery over a longer time period than the first 10 days after operation. Radiographic control examinations revealed tumour recurrences in 2 patients (both asymptomatic) and progress of residual tumour in 5 patients (2 symptomatic, 3 asymptomatic). Since introduction of modern neurosurgery, a clear improvement in the surgical treatment of suprasellar meningiomas can be observed. However, the still long delay in diagnosing these tumours correctly prevents a further improvement of the ophthalmological results at long-term follow-up. Due to a relatively high rate of late onset epilepsy, anticonvulsive prophylaxis for 6 months seems to be justified. Regarding present pre-operative diagnostic measures, ia-DSA seems only be indicated in patients with CT/MRI-scans, suspicious for tumourous narrowing or invasion of major cerebral arteries. In addition, we recommend radiographic control examinations at regular time intervals to confirm radical tumour removal and to detect the “ideal” point of time for renewed treatment.
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  • 8
    ISSN: 1432-1920
    Keywords: Vascular anomaly ; Vertebral artery ; Vertebral angiography ; Interior thyroid artery ; Thyroid surgery
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Summary The known rare occurrence of related anomalies of origin of vertebral and inferior thyroid arteries appears not to be documented in the angiographic literature. Three cases with manifestation on the left side are presented. Embryology is discussed briefly. Knowledge of such anomalies is of importance to surgeons as well as angiographers.
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