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OBJECTIVE—Synovial cysts of the vertebral facet joints are a source of nerve root compression. Different surgical procedures are in use, but no consensus has been formed so far as to which method should be used in synovial cysts. To clarify the role of surgical management, the efficacy of operative procedures and factors influencing the outcome in our own series of 19 patients treated between 1994and 1998 were analysed. METHODS—Nineteen patients with a mean age of 65 years underwent surgery for medically intractable radicular pain or neurological deficits caused by synovial cysts. The patients' records were retrospectively analysed for neurological deficits, cysts diameter, operative approach, segmental hypermobility, and clinical outcome; CT and MRI were analysed for additional degenerative changes. RESULTS—In 17 patients an excellent result and in two patients a good postoperative result was achieved. Twelve patients were found to have hypermobility of the facet joints and six had spondylolisthesis. There was no correlation between cyst diameter, operative approach, and outcome. No intraoperative or postoperative complications occurred. CONCLUSIONS—Age and hypermobility may play a part in the aetiology of facet joint synovial cysts. As all operative strategies showed equally good clinical outcome, total excision via a small flavectomy as the least invasive approach should be considered therapy of choice in patients with cysts causing neurological deficits.

Grundlagen: In einer retrospektiven Studie wurden die Krankengeschichten von 210 Patienten mit spontanen intrazerebralen Hamatomen aus den Jahren 1980 bis 1990 untersucht, um das Behandlungsergebnis und die Effizienz der Neuroendoskopie mit der konventionellen Kraniotomie und dem konservativen Vorgehen zu vergleichen. Ausgeschlossen wurden Patienten mit Aneurysmen, arteriovenosen Malformationen, Hirntumoren und Kopfverletzungen. Methodik: Aufnahmezustand (GCS=Glasgow Coma Scale), Behandlungsmethode, Alter, Hamatomgrose, Lage der Blutung und Ventrikeleinbruch sowie das Behandlungsergebnis (GOS=Glasgow Outcome Scale) nach 6 Monaten wurden miteinander verglichen. Je 70 Patienten fanden Aufnahme in einer der drei Behandlungsgruppen. Ergebnisse: Prognostisch ungunstig waren ein GCS von 3–6 sowie ein Alter von 65–80 Jahren; des weiteren ist bei einer Hamatomgrose>50 cm3 und einem Ventrikeleinbruch mit einer schlechteren Prognose zu rechnen. Die lobaren Blutungen hatten ein besseres Behandlungsergebnis als die tiefen Blutungen (Thalamus, Putamen), wahrend die Behandlungsmethode nur einen tendenziellen Einflus auf die Lebensqualitat ausubte (besserer GOS in der Reihenfolge konservativ — endoskopisch — operativ). Schlusfolgerungen: Insgesamt zeigte sich ein hoheres Mortalitatsrisiko fur die konservativ Behandelten gegenuber den endoskopisch und operativ Behandelten, wobei jedoch nur die neurochirurgischen Patienten postoperativ an einer Intensivstation Aufnahme fanden. Fruhe Nachblutungen waren in der operativ und besonders in der endoskopisch behandelten Gruppe deutlich haufiger.

Grundlagen: Zielsetzung dieser retrospektiven Untersuchung war es, anhand klinischer Parameter eine Prognose der posttraumatischen intrakraniellen Infektion zu erstellen und daraus therapeutische Richtlinien abzuleiten.

Glomus tumors (GT) of the skull-base present a complex surgical challenge due to their delicate localization and specific vascular supply. This study is designed to evaluate the role of stereotactic radiosurgery in the treatment of GT. Thirteen patients with GT have been treated with the Gamma Knife. Radiosurgery was performed because of recurrences after surgical removal in six patients. Histology was not available in seven patients, thus, diagnosis was made from neuroradiological features only. Two of them had partial embolization before Gamma Knife treatment. Clinical and morphological data were collected from 11 patients, who had a representative follow-up of at least 12 months. Mean follow-up was 42 months (range 14 to 72 months). Within the follow-up period there was no tumor progression and no clinical deterioration in any of the patients. 64% of the patients had an improvement of their symptoms, and in 36% the volume of the lesion decreased in size. There was no radiation-related morbidity. It is suggested that radiosurgery seems to be safe and effective in the treatment of GT.

43 patients with meningiomas of the cavernous sinus form the basis of this study. Two patients were treated with microsurgery alone, 17 patients were treated by Gamma Knife radiosurgery (GKRS) as a primary treatment modality, and 24 patients underwent a combined treatment of microsurgery followed by GKRS. Therefore, in 17 patients the diagnosis rested on clinical and radiological criteria alone. Cranial nerve disorders (CND) related to open surgical treatment were infrequent in this material (3 of 13 patients) due to deliberate strategies of partial or subtotal resection aimed at sparing cranial nerves from surgical maneuvers. In contrast, 6 of 11 patients, admitted for GKRS from other institutions suffered from considerable CND after open surgery and showed only partial improvement after GKRS. In all GKRS cases, no radiation-related complications were seen after a follow-up of 18–62 months (mean 39 months). Moreover, in all cases tumor control was obtained with a stable tumor volume in 63%, reduction of volume in 34.5% and a disappearance of tumor in 2.5%. GKRS is not only an additional treatment for meningiomas involving the cavernous sinus, but may be offered to the patient as an alternative primary treatment.

Six cases of acoustic neurinomas with macrocystic components are presented. In three cases the cystic portion was within the tumor, while in the other three, the cyst was peritumoral, in the form of a cul-de-sac within the arachnoid, in other words it was not a true tumor cyst. The six tumors are from a series of 74 acoustic neurinomas treated by radiosurgery with a minimum follow-up of 18 months. In all cases, enlargement of the associated cyst was observed as early as 4 months after radiosurgery. Clinical signs and symptoms such as facial weakness, trigeminal symptoms, vertigo and dizziness and coordination disorders developed between 4 and 8 months. In three cases (two intramural cysts and one combined peri- and intramural cyst), subacute microsurgery was performed to treat the progression of neurological symptoms. One case had spontaneous rupture of an intramural cyst, one case of a peritumoral cyst, after progression showed a slow spontaneous size decrease after 2 years, and one case is still under observation. In the reported series, the dose at the tumor margin ranged between 11 and 17 Gy (mean 13.8 +/- 2.5 [SD] Gy) and the maximal dose between 24 and 40 Gy (mean 30.6 +/- 6.2 Gy). In view of the findings in this study, one should perhaps be cautious in advising radiosurgery for this subgroup of acoustic tumors.

Objectives: As most reports on the gamma knife have related only to short or mid-term results, we decided to evaluate the effectiveness and toxicity of radiosurgical treatment for benign skull base meningiomas in 200 patients with a follow up of 5–12 years to define the role of gamma knife radiosurgery (GKRS) for basal meningiomas and to provide further data for comparison with other treatment options. Methods: In total, 99 patients were treated with a combination of microsurgical resection and GKRS. In 101 patients, GKRS was performed as the sole treatment option. Tumour volumes ranged from 0.38 to 89.8 cm3 (median 6.5 cm3), and doses of 7–25 Gy (median 12 Gy) were given to the tumour borders at covering isodose volume curves (range 20–80%, median 45%). Results: The actuarial progression free survival rate was 98.5% at 5 years and 97.2% at 10 years. Passing radiation induced oedema occurred in two patients (1%). The neurological status improved in 83 cases (41.5%), remained unaltered in 108 (54%), and deteriorated in 9 (4.5%). Worsening was transient in seven patients (3.5%) and unrelated to tumour or treatment in one (0.5%). Repeated microsurgical resection was performed in five patients following GKRS (2.5%). Conclusions: GKRS has proved to be an effective alternative to microsurgical resection, radiotherapy, and Linac based radiosurgery for adjunctive and primary treatment of selected patients with basal meningiomas. Because of the excellent long term tumour control rate and low morbidity associated with GKRS, this treatment option should be used more frequently in the therapeutic management of benign skull base meningiomas.

Grundlagen: In der kritischen Literatur wird immer wieder von Problemen mit hydrozephalen Entwicklungen nach Gamma-Knife-Radiochirurgie berichtet. Ziel dieser Untersuchung ist die Uberprufung dieser Hypothese an unserem eigenen Patientenkollektiv.

A case of a ruptured saccular aneurysm arising from the proximal portion of a partially duplicated basilar artery in a 36-year-old woman is reported. CT and lumbar puncture confirmed subarachnoid haemorrhage. Cerebral angiography detected a vertebrobasilar junction aneurysm associated with basilar artery fenestration. The patient underwent successful clipping and coating of the aneurysm by a right lateral suboccipital osteoclastic approach. Embryological development, pathogenesis, diagnostic and therapeutic difficulties of this vascular malformation are discussed in this report.