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Objective Currently, the standard practice to treat intradural spinal tumours involves microsurgical resection of the lesions. It is essential to be able to locate the lesion precisely to reduce the risk of neurological morbidity. The purpose of this study was to evaluate intraoperative ultrasonography (IOUS) in visualizing intradural spinal tumours, and assess its potential to improve surgical precision and minimize surgical trauma. Methods Between January 2006 and July 2007, 30 patients with suspected intradural spinal tumours underwent surgery with the aid of IOUS. There were 13 patients with intramedullary tumours (ependymoma = 2, astrocytoma = 5, hemangioblastoma = 2 and metastasis = 4); and 14 patients with extramedullary tumours (meningioma = 6, neurinoma = 6, filum terminale ependymoma = 1 and lipoma = 1). In 3 patients histopathology did not reveal any neoplasm despite an MRI suggesting tumour. Their sonographic features are analyzed and the advantages of IOUS are discussed. Results The shape and expansion of intradural tumours could be visualized on IOUS. The sonographic visualization allowed adapting the approach to an appropriate location and size before dura opening. Certain sonographic features can be used for a differential diagnosis of different intradural tumours. In addition, IOUS can inform neurosurgeons about the location of the neoplastic tissue, its relation to the spinal cord and the size of residual tumour following excision. Conclusions IOUS is a sensitive intraoperative tool. When appropriately applied to assist surgical procedures, it offers additional intraoperative information that helps to improve surgical precision and therefore might reduce the procedure related morbidity.

Background Intraoperative US has been widely used in neurosurgical procedures. However, images are often difficult to read. In the present study, we evaluate whether the image guidance of ultrasonography is helpful for the interpretation of US scans. Methods Twenty-nine patients with tumor were operated on with the aid of intraoperative US from January to June 2005. Image-guided sonography was used in 13 cases and nonnavigated US technology in the remaining cases. We compared the 2 technologies retrospectively. Results Although image quality was good in most cases, orientation remained difficult in 8 of the 16 patients where conventional sonography was used. With the aid of image fusion for navigated sonography, the orientation was judged superior to nonnavigated US. Conclusion In our experience, integration of the US into the navigation system facilitates anatomical understanding. Thus, we feel that this technology is beneficial for neurosurgical routine.

High-resolution magnetic resonance imaging (HR-MRI) using three-dimensional fast imaging employing steady-state acquisition (3D-FIESTA) and double-dose contrast-enhanced three-dimensional fast spoiled gradient echo (3D-FSPGR) sequences is considered to be a useful tool in detecting neurovascular compression in patients with trigeminal neuralgia. The purpose of this study was to analyze the accuracy and preoperative diagnostic value of these high-resolution imaging techniques in patients with trigeminal neuralgia, in a single-blind study. The preoperative MRI images of 21 consecutive patients were matched to one neuroradiologist, who was blind as to which side exhibited the symptoms. The images and post-processing multiplanar reconstructions were compared with the video-documented operative observations. HR-MRI using only 3D-FSPGR sequences demonstrated neurovascular compression in accordance with the intraoperative finding in 11 patients (52.4%). In the subgroup where, additionally, 3D-FIESTA sequences were available, neurovascular compression was in accordance with the intraoperative finding in 71.4% (n = 7). High-resolution magnetic resonance imaging using double-dose contrast-enhanced 3D-FSPGR and 3D-FIESTA sequences is currently not sufficient enough to make an accurate prediction of neurovascular compression in a single-blind setting. These 3D imaging techniques currently provide only limited information, and one should consider their use carefully when identifying patients with trigeminal neuralgia from operation until image quality is improved by superior image resolution that can accurately discriminate vessels surrounding the trigeminal root entry zone.

The authors report the successful surgical resection of brainstem cavernous angiomas in a series of 42 consecutive patients. There were 22 females and 20 males whose ages ranged from 16 to 62 years with a mean of 39.5 years. Twelve lesions were located within the midbrain, 25 in the pons and 5 in the medulla. Immediately following the procedure, 3 patients showed dramatic clinical improvement, 30 patients had no additional neurological deterioration, 9 individuals developed new deficits or an accentuation of preoperative symptoms. There were no major complications and no mortality in this series. At follow-up ranging from 6 months to 7 years (mean 3 years), one patient remained with a permanent oculomotor paralysis and two others with a slightly accentuated gait ataxia. The vast majority of the remaining 39 individuals have experienced a clinical improvement of preoperative symptoms. All 42 patients in this series lead an independent life and none has suffered any further brainstem hemorrhage after surgery. A careful selection of the surgical approach and optimal entry zone into the brainstem play a major role for the success of the procedure. With a meticulous microsurgical technique, even deeply located intra-axial brainstem cavernomas can be removed without creating additional morbidity.

Background: Gliomas are the most common primary tumours of the central nervous system and exhibit rapid growth that is associated with neovascularisation. Adrenomedullin is an important tumour survival factor in human carcinogenesis. It has growth promoting effects on gliomas, and blockade of its actions has been experimentally shown to reduce the growth of glioma tissues and cell lines. There is some evidence that the calcitonin receptor-like receptor (CRLR) mediates the tumorigenic actions of adrenomedullin. Aim: To determine whether CRLR is expressed in human gliomas and the probable cellular targets of adrenomedullin. Methods: Biopsies from 95 human gliomas of varying grade were processed for immunohistochemical analysis using a previously developed and characterised antibody to CRLR. Results: All tumour specimens were positive for CRLR. As previously found in normal peripheral tissues, CRLR immunostaining was particularly intense in the endothelial cells. This was evident in all the various vascular conformations that were observed, and which are typical of gliomas. In addition, clear immunostaining of tumour cells with astrocyte morphology was observed. These were preferentially localised around vessels. Conclusions: This study has shown for the first time that the CRLR protein is present in human glioma tissue. The expression of the receptor in endothelial cells and in astrocytic tumour cells is consistent with the evidence that its endogenous ligand, adrenomedullin, may influence glioma growth by means of both direct mitogenic and indirect angiogenic effects. CRLR may be a valuable target for effective therapeutic intervention in these malignant tumours.

OBJECTIVE: To devaluate technical and methodological aspects of intraoperative spinal digital subtraction angiography (ISDSA) in our clinical practice and to assess its practicability, safety, and accuracy for the surgical treatment of spinal vascular malformations. METHODS: Between August 1997 and February 2002, a total of 30 partients were treated either surgically (n = 18) or endovascularly (n = 12) for spinal vascular lesions at our institution. The clinical records of live patients who underwent ISDSA were analyzed retrospectively. The thoracic segment was involved in three patients and the medullary cone in two. RESULTS: ISDSA could be performed in four cases, in one patient, the segmental artery could not be probed sufficiently while the patient was prone, No complications occurred from the application of ISDSA. The method was beneficial for the neurosurgeon ito all but one patient because the vascular anatorny of the malformation was shown with respect to the sugical approach, including the nidus, and immediate ; resection control could be performed before wound closure. The duration of the procedure was prolonged by 45 minutes on average. CONCLUSION: ISDSA is safe and effective, especially in surgery for complex vascular and recurrent malformations. Benefits to the patient outweigh the additional expense and prolongation of the surgical procedure.

Introduction. The development of fusiform dilatation of internal carotid artery is one of the vascular complications that can follow surgery for craniopharyngioma and other suprasellar tumours in children, but its pathogenesis and the line of management are still controversial. Case report and discussion. We report a child who presented with a giant fusiform aneurysm involving the supraclinoid portion of the internal carotid artery after total removal of a craniopharyngioma and review the literature on related cases. The treatment of this phenomenon and its possible pathogenesis are discussed.

The recent "Report of the ILAE Commission on Classification and Terminology" recommends an epilepsy classification that gives more emphasis to the underlying structural or metabolic cause rather than to the localization of the epileptogenic zone. The aim of the present study was to investigate differences in clinical features, treatment response, and prognosis in patients with mesial temporal lobe epilepsy (MTLE) caused by hippocampal sclerosis (MTLE-HS) or singular mesiotemporal cavernomas (MTLE-C) in order to evaluate the impact of underlying pathology on the course of the disease while controlling for localization.Age at onset, age at surgery, seizure frequency and semiology, pharmacoresistance, psychiatric comorbidities, memory deficits, or initial precipitating insults (e.g., febrile seizures, traumatic brain injury, infection of the central nervous system, birth complications) as well as postoperative outcome were compared in eleven patients with MTLE-C and 33 patients with MTLE-HS using nonparametric statistical methods.The postoperative outcome was significantly better in patients with MTLE-C, even after controlling for preoperative epilepsy duration. Patients with MTLE-HS more frequently were drug resistant (88% vs. 36%) and more often presented with an initial precipitating insult (70% vs. 27%) and with automotor seizures (79% vs. 46%).The results suggest that patients with MTLE-C show a more favorable postoperative outcome, supporting the commission's suggestion to put more emphasis on the underlying cause in future epilepsy classifications.

Objective This investigation was performed to evaluate the specific procedural issues and indications of a surgically assisted Doppler-guided endovascular transfalcine venous approach for the treatment of vein of Galen aneurysmal malformations (VGAM) in critically ill neonates. Patients and methods Two neonates out of a clinical series of 15 children (8 males and 7 females) with vein of Galen malformations were treated by our neurovascular team, using a combined surgically assisted endovascular transfalcine approach. In the biplanar angiography room a radiographically guided craniotomy (1.5 cm) was placed over the cranial projection of the falciforme sinus. After craniotomy the orthograd flow of the falciforme sinus was identified by Doppler ultrasonography. The sinus was punctured by an i. v. cannula with injection port and was sutured to the skin. A microcatheter was maneuvered over a guide into the malformation under fluoroscopic control. For embolization Guglielmi electrolytically detachable platinum coils were placed into the malformation as an embolic agent. Neurological examination records, available MR images, computed tomographic scans, pre- and postembolization angiograms and follow-up data were analyzed. Results In both individuals the malformation was classified as VGAM. The follow-up was 6 and 7 months, respectively. No technique associated morbidity or mortality occurred in the present series. At discharge both selected neonates were in stable condition and the flow in the VGAMs could be significantly reduced by a combination of approaches including the venous transfalcine approach. Meanwhile, 6 months after birth one neonate died due to a deterioration of the pulmonary hypertension. Conclusions Endovascular treatment is presently the most efficient strategy to allow neonates and infants survive the early manifestation of vein of Galen malformations and probably render a normal neurological development. Consequently, a combination of approaches in selected cases including the Doppler guided venous transfalcine route should be regarded as a preferential treatment modality, especially in patients with arterial vasospasms and venous stenosis.