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Objective The number of patients who need cranioplasty after decompressive craniectomy has increased. In most cases, autologous bone flaps are used for cranioplasty, and there have been reports of the complication of bone flap resorption. Based on these facts, we analysed patients who underwent cranioplasty in our institution to learn about potential risk factors of cranioplasty. Methods and results We performed a retrospective study and analysed 58 patients who underwent cranioplasty between 2006 and 2013. We found that patients with a defect size >120cm 2 whose reimplantation was delayed tended to have a risk of bone flap resorption. Conclusion Patients with delayed reimplantation and a defect size >120cm 2 show a tendency of aseptic bone flap resorption. In these cases, a patient-specific implant (PSI) could be the first choice material for this procedure to reduce the rate of this complication.

Study Design. Prospective cohort study. Objective. We performed a prospective cohort study with standardized postoperative lumbar imaging every 3 months for a year then annually to assess the incidence and factors associated with same-level recurrent disc herniation. Summary of Background Data. The true incidence of same-level recurrent disc herniation after lumbar discectomy is unclear. Retrospective studies have reported widely varying incidences between 3% and 18%. Prospective controlled studies are lacking. Methods. A total of 108 patients undergoing first-time lumbar discectomy for refractory radiculopathy were enrolled. Baseline lumbar CT and MRI and standardized clinical data were assessed before surgery, and CT and MRI scans repeated 6 weeks, 3, 6, 9, 12, and 24-months after surgery and at the time of recurrent sciatica. Age, weight, preoperative disc volume, and height, volume of disc removed, and size of anular defect were compared with postoperative disc height loss and-recurrent disc herniation using regression analysis. Results. One hundred patients (41 ± 10 years old) were available for 1-year (93%) and 76 (70%) for 2-year follow-up (mean follow-up: 25 ± 12 months). Improvement in all outcome measures was observed by 6 weeks after surgery (P< 0.005). An 18% loss of disc height was observed 3 months after surgery, progressing to 26% by 2 years. Eleven (10.2%) patients experienced recurrent disc herniation requiring revision discectomy a mean 10.5 months after surgery. Subjects with larger anular defects (P = 0.019) and with smaller percentage of disc volume removed (P = 0.028) were associated with an increased risk of recurrent disc herniation. Conversely, those from whom greater disc volumes were removed (P = 0.024) had more progressive disc height loss by 6 months after surgery. Conclusion. Larger anular defects and less disc removal increased the risk of reherniation. Greater volumes of disc removal were associated with accelerated disc height loss. In the setting of larger anular defects or less aggressive disc removal, concern for recurrent herniation should be increased during outpatient follow-up. In this situation effective anular repair may be helpful.

A cystic lesion adjacent to the dens with compression of the lower portion of the medulla oblongata was found on MRI in a 75-year-old male patient with a 2-month history of occipital pain and gait disturbance. Clinically, the patient showed mild tetraparesis, signs of spinal ataxia and symmetrical hyperreflexia. Following subtotal removal of the cyst via left-sided suboccipital craniotomy and left-sided hemilaminectomy of C1 the lesion was classified as synovial cyst on histopathological examination. Postoperatively, the quadriparesis almost completely subsided and the patient is currently doing well, 33 months after surgery. Synovial or ganglion cysts adjacent to the atlantoaxial articulation with ventral compression of the cervicomedullar cord represent rare surgical or radiological entities. Atlantoaxial synovial cysts have no typical radiographic appearance or specific neurological symptoms so that they are frequently misdiagnosed as intraspinal- or skull base tumour, rheumatoid lesion or ectatic vertebral artery. Since no ensuing complications or recurrences have been encountered in cases of incompletely removed cysts the less invasive operative approaches should be used to avoid destabilisation and subsequent additional surgical procedures.

Background: The prevailing percutaneous treatment options for herniated non-contained lumbar discs have not reliably achieved the same good results as the conventional microsurgical techniques. In this study we evaluated clinical outcome and complication rate following endoscopic percutaneous transforaminal treatment of extruded or sequestrated herniated lumbar discs in 122 patients with a follow-up period of more than one year. Method: Between October 1997 and December 2000, 86 male and 36 female patients with a median age of 55 years (range 18 to 89 years) underwent endoscopic treatment for non-contained herniated lumbar discs at our department. Neurological controls were conducted after 4 to 8 weeks routinely and the clinical result was reassessed at a follow-up of 15 to 53 months (median 35 months) according to the Macnab scale and Prolo outcome score. Findings: On follow-up examination, 96 patients were found with permanently ameliorated or normal clinical status following endoscopy alone. The remaining 26 cases with unchanged or only temporarily improved neurological disorders were submitted to conventional microsurgical interventions. Spinal nerve root injury during endoscopic treatment occurred in two patients but no additional neurological deficits or aggravation of pre-existing disorders were observed. Interpretation: Due to the minimal invasivity, the good functional outcome (78.7% clinical amelioration) and the low complication rate (1.6%), this procedure represents an attractive and efficient treatment alternative especially for foraminal and extraforaminal herniated lumbar discs and reduces the indications for open surgery in selected cases.

Radiosurgery is either a primary or an adjunctive management approach used to treat patients with vestibular schwannomas. We sought to determine outcomes measuring the potential benefits against the neurological risks in patients who underwent radiosurgery after previous microsurgical subtotal resection or recurrence of the tumour after total resection. Gamma Knife radiosurgery was applied as an adjunctive treatment modality for 86 patients with vestibular schwannomas from April 1992 to August 2001. We evaluated the results of 50 patients who had a follow-up of at least 3.5 years (median 75 months, range 42-114 months). In 16 patients a recurrence of disease was observed after previous total resection. The median treatment volume was 3.4 ccm with a median dose to the tumour margin of 13 Gy. Tumour control rate was 96%. Two tumours progressed after adjunctive radiosurgery. Useful hearing (Gardner-Robertson II) (4 patients (8%)) and residual hearing (Gardner-Roberson III) (10 patients (20%)) remained unchanged in all patients, who presented with it before radiosurgery, respectively. Clinical neurological improvement was observed in 24 patients (46%). Adverse effects comprised transient neurological symptoms and signs (incomplete facial palsy, House-Brackman II/III) in five cases (recovered completely), mild trigeminal neuropathy in four cases, and morphological changes displaying rapid enlargement of a pre-existing macrocyst in one patient and tumour growth in another one. No permanent new cranial nerve deficit was observed. Radiosurgery appears to be an effective adjunctive method for growth control of vestibular schwannomas and is associated with both a low mortality rate and a good quality of life. Accordingly, radiosurgery is a rewarding therapeutic approach for the preservation of cranial nerve function in the management of patients with vestibular schwannoma in whom prior microsurgical resection failed.

The purpose of the study was to determine the frequency of associated MR imaging findings in patients with symptomatic lumbar intraspinal synovial cysts, and to correlate MR with surgical findings. MR imaging studies of 18 patients with surgically and histopathologically proven lumbar intraspinal synovial cysts were retrospectively analyzed and correlated with surgical findings. The diameters of the synovial cysts ranged from 10 mm to 28 mm, with a mean of 16 mm. A nonhemorrhagic cyst was found in 15 patients (83%), and a hemorrhagic cyst in three patients (17%). Degenerative spondylolisthesis was found in six patients (33%) at the level of the synovial cyst, with displacement ranging from 3 to 5 mm, mean 4 mm. Surgery revealed instability and hypermobility of the facet joint at the level of the synovial cyst in all patients with degenerative spondylolisthesis, and in five additional patients. Symptomatic synovial cysts of the lumbar spine were associated with degenerative spondylolisthesis in six of 18 patients (33%) and with instability of the facet joint in 11 (61%). These findings may support the theory that increased segmental motion plays a role in the pathogenesis of synovial cysts.

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.

From April 1992 to July 1998 stereotactic radiosurgery (Gamma Knife) was used to treat 1382 patients; 181 had acoustic neurinomas and were followed up, 44 of them for at least 4 years (48-75 months, median 60). With no mortality control of growth tumor was achieved in all cases but one. It was possible to preserve useful hearing in more than half of the patients (60%). In two patients complications due to the radiation with enlargement of the cystic component were observed. One patient needed additional microsurgical decompression. Three patients suffered transient incomplete facial palsy (one permanent, HBI III), and two patients complained of mild trigeminal neuropathy. One suffered from hydrocephalus and a shunting procedure was necessary. The neurological state improved in 23 patients (52%); five complained of new or worsened deficits. Radiosurgery is an effective alternative treatment for acoustic neurinomas with exceptionally low mortality and morbidity. With respect to preserving cranial nerve function the results are just as good as those of microsurgical resection. Short duration of hospitalization and quick return to normal activities make radiosurgery quite cost effective.

¶ From April 1992 till December 1998 stereotactic radiosurgery (Gamma Knife) was applied to 192 patients with vestibular schwannomas. 56 of them had radiosurgery as primary treatment modality and were followed-up for at least 4 years (48–80 months, median 62). Without fatal complications, control of tumour growth was achieved in all but three cases, useful hearing being preserved in more than one half of the patients (62%). The neurological state improved in 30 patients (54%). Irradiation-associated adverse effects (18%) comprised neurological signs (incomplete facial palsy, four cases (two recovered completely), and mild trigeminal neuropathy, three cases, respectively) and morphological changes (three patients) marked by an enlargement of pre-existing cystic components calling for additional surgical treatment: Microsurgical decompression was performed in two cases, the third patient underwent a shunting procedure because of hydrocephalus formation. Based on the present data, radiosurgery represents an effective treatment for vestibular schwannomas associated with an exceptionally low mortality rate and a good quality of life. With respect to the preservation of cranial nerve function, results are comparable to microsurgical resection. A short duration of hospitalization and a quick return to normal activities constitute further advantages and contribute to cost effectiveness in public health care.

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.

The aim of this clinical study was to determine the tumour control rate, clinical outcome and complication rate following gamma knife treatment for glomus jugulare tumours. Between May 1992 and May 1998, 13 patients with glomus tumours underwent stereotactic radiosurgical treatment in our department. The age of these patients ranged from 21 to 80 years. The male : female ratio was 2 : 11. Six patients had primary open surgery for partial removal or recurrent growth and subsequent radiosurgical therapy. Radiosurgery was performed as primary treatment in 7 cases. The median tumour volume was 6,4 cm3 (range: 4,6–13,7 cm3). The median marginal dose applied to an average isodose volume of 50% (30–50%) was 13,5 Gy (12–20 Gy). In 10 patients, a total of 48 MRI and CT follow-up scans were available. The remaining three patients have been excluded from the postradiosurgical evaluation since the observation time (t

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

Lumbar discectomy is an effective treatment for lumbar disc herniation (LDH). Although the majority of patients experience successful outcomes, a significant fraction will experience a recurrence of their back pain due to facet joint degeneration. Facet joint degeneration after discectomy may be the result of excessive nuclear removal, disc space narrowing, and annular injury. This study investigated whether implantation with the Barricaid annular closure device (ACD) during discectomy reduced the rate of facet degeneration. Inclusion criteria were primary lumbar disc herniation failing conservative treatment, Visual Analog Scale (VAS) Leg ≥ 40/100, Oswestry Disability Index (ODI) ≥ 40/100 and defects that were ≤60 mm2 (Barricaid arm only), and patient age 18–75. CT interpretations were collected preoperatively and 12 months post-discectomy. Patients implanted with Barricaid had significantly reduced rates and grades of facet degeneration than patients without Barricaid. Reinforcing the annulus fibrosus with Barricaid during lumbar discectomy may slow the progression of facet joint degeneration.

Grundlagen: Zahlreiche Studien unterstreichen die Aussagekraft der initialen Glasgow Coma Scale (GCS) nach einem Schadel-Hirntrauma fur den weiteren klinischen Verlauf. Ziel dieser retrospektiven Studie war es, prognostische Faktoren fur den klinischen Ausgang von Kindern mit traumatischen Hirnstammlasionen zu ermitteln. Methodik: Insgesamt wurden in den letzten 16 Jahren 1108 Kinder mit einem Schadel-Hirntrauma untersucht, wovon 23 Patienten klinische und/oder radiologische Zeichen einer Hirnstammlasion aufwiesen. Die initiale neurologische Beurteilung erfolgte durch Bewertung mit dem GCS. Unsere Studie verglich den initialen GCS mit dem klinischen Verlauf unter Zuhilfenahme der Glasgow Outcome Scale (GOS). Ergebnisse: Bei 13 Patienten (57%) waren neben der Hirnstammsymptomatik entsprechende morphologische Lasionen in der CT bzw. MRI erkennbar. 7 Patienten (30%) wiesen nur klinische Zeichen einer Hirnstammaffektion auf, wahrend 3 Patienten (13%) eindeutig morphologische Lasionen ohne entsprechendes klinisches Korrelat zeigten. Patienten mit einem GCS von 3 bis 4 Punkten (n = 15) zeigten einen signifikanten Unterschied (p < 0,001) im Langzeitverlauf (GOS) gegenuber jenen Patienten (n = 8) mit einem initialen GCS von 5 bis 7 Punkten. Schlusfolgerungen: Die Ergebnisse lassen einen direkten Zusammenhang zwischen Ausgang und initialem klinischem Befund erkennen, jedoch keinen mit dem im CT verifizierten Befund. Hinsichtlich der Hirnstammlasionen erwies sich das MRI als die sensitivere Methode.

Grundlagen: Zielsetzung dieser retrospektiven Studie war es, anhand klinischer und morphologischer Parameter Kriterien zur intrakraniellen Druckmessung zu erstellen. Methodik: Seit 1985 wurde am Grazer Klinikum bei 26 Patienten im Alter zwischen 4 und 17 Jahren die Indikation zur kontinuierlichen Hirndruckmessung gestellt. Diese Patienten erlitten im Rahmen von Unfallen ein schweres Schadel-Hirn-Trauma, welches eine neurointensivmedizinische Therapie notwendig machte. Die Indikationsstellung erfolgte bei Glasgow Coma Score (GCS) 7 oder niedriger, bei Bewustlosigkeit und pathologischem kranialem CT oder bei geplanter langerer Intubationsdauer. Untersucht wurden der GCS am Unfallort, initiale Neurologie und CT, Verlauf des intrakraniellen Drucks (ICP), Kontroll-CT und Glasgow Outcome Score (GOS) (5) (Tab. 1). Ergebnisse: Bei 25 der 26 Patienten (96,15%) fand sich ein deutlicher Zusammenhang zwischen ICP und GOS. Ein Patient mit einer isolierten Verletzung des Hirnstamms zeigte nur geringe Erhohung des ICP, trotzdem hatte sich der klinische Verlauf ungunstig gestaltet. Der initiale GCS und das neurologische Endresultat zeigten im gesamten Kollektiv keine Korrelation (Abb. 1). Schlusfolgerungen: Die kontinuierliche ICP-Messung ist bei schwerem SHT als unverzichtbarer Bestandteil im Intensivmanagement des neurotraumatologischen Patienten anzusehen.

Aetiology and pathogenesis of eating disorders is a matter of controversy. In some cases they can occur in association with tumours involving the temporal cortex, in temporal lobe epilepsy or in the advanced state of degenerative diseases involving temporal structures. We report about three patients with right frontal intracerebral lesions, one oligo-astrocytoma and two vascular malformations, associated with partial seizures and anorexia nervosa. 3 patients, one female and two men with anorexia nervosa and right frontal intracerebral lesions were admitted to our wards due to focal seizures or loss of consciousness. They were treated either microsurgically or by endovascular embolization after neuro-imaging. In our retrospective analysis of the patients' reports and course we investigated the histopathology of the lesions, duration of the eating disorder and the clinical outcome. Two patients underwent craniotomy with extirpation of the lesion. In one case histology revealed an oligo-astrocytoma, in the other haemorrhagic infarction due to a venous malformation. The patient with the arteriovenous malformation (AVM) was embolized with microparticles. The patients with the oligoastrocytoma and AVM totally recovered. They gained weight and stayed seizure free. The patient with the infarction remained in a vegetative state. Right frontal intracerebral lesions with their close relationship to the limbic system could be causative for eating disorders. We therefore recommend performing a cranial MRI in all patients with suspected eating disorders, especially if they occur in combination with focal seizures.

Introduction. Microsurgical excision with preservation of juxtaposed neurovascular structures is considered the treatment of choice for skull base meningiomas, but there exists a great controversy regarding surgical resectability, potential risk for subsequent postoperative Cranial Nerve Deficit (CND) and the role of adjuvant or adjunctive treatment options. In this study we evaluated the effect of Gamma Knife Radiosurgery (GKRS) in 121 patients with benign basal meningiomas after a follow-up of 5 to 9.8 years.

In the last few years, tuberculosis has evolved to become a major public health problem again. One reason, of course, is the growth in international travel and trade, which provides many more opportunities for the spread of diseases. Other risk factors are the increasing prevalence of HIV infection as well as urban overcrowding and inadequate nutrition.1–3 Tuberculosis primarily affects the lungs and then spreads to the other parts of the body through the blood stream. It is estimated that the central nervous system is affected in 10% of all patients diagnosed with tuberculosis. The most common manifestation is tuberculous meningitis.2 Spinal involvement is estimated to be only 2–5% of all cases.4 Primary spinal tuberculosis is extremely rare and only four cases have been reported in the literature until now.5 In this paper, we present a case of a woman in her 40s in whom a primary intradural extramedullary tuberculoma was diagnosed. She complained of general symptoms but no other abnormalities were found. A woman in her 40s was admitted to our department with a 2-year history of recurrent low-back pain and ischialgia in both lower extremities. Deterioration of her symptoms occurred over the last month. In addition, she suffered from weakness in general, chronic fatigue and night sweat; however, she denied other serious diseases, although she confessed to alcohol abuse a few years ago. Due to aches and pains she had to take medication (non-steroidal anti-inflammatory drugs and opioids) regularly three …

BACKGROUND Meralgia paresthetica, a syndrome of pain and/or dysesthesia in the anterolateral thigh, is normally caused by an entrapment of the lateral femoral cutaneous nerve (LFCN) at the anterior superior iliac spine. In a few cases compression of the nerve in the retroperitoneum has been reported to mimic meralgia paresthetica. CASE DESCRIPTION A 67-year-old woman presented with a 5-year history of permanent paresthesia in the anterolateral thigh. Motor weakness was not detected. Electromyography showed a neurogenic lesion at the level of L3. Lumbar spine MRI detected a foraminal-extraforaminal disc herniation at L2/L3, which was extirpated via a lateral transmuscular approach. The patient was free of symptoms on the first postoperative day. CONCLUSION In patients with meralgia paresthetica we emphasize a complete radiological investigation of the lumbar spine, including MRI, to exclude radicular compression by a disc herniation or a tumour at the level of L2 or L3.

We reviewed the medium-term results of endovascular treatment of intracranial aneurysms and compared patient selection and results with those of open surgery. Between January 1992 and December 1995, a total of 248 consecutive patients were treated for 297 aneurysms (61 unruptured and 236 ruptured). 162 aneurysms in 142 patients (mean age, 48.5 years) were treated microsurgically and 134 aneurysms in 106 patients (mean age, 54.2 years) were treated by endovascular embolization with Guglielmi detachable coils (GDC). The mean follow-up was 2.6 years (range, 1.5 to 4.5 years). There was no significant difference in patient population and selection in terms of age, sex or location of aneurysms between both methods. Both modalities achieved excellent results (defined as no neurological deficit) in patients with unruptured aneurysms and with no or minor deficits after subarachnoid hemorrhage (SAH) between 71% and 88%. Patients with moderate deficits after SAH had excellent outcomes in 49% after open surgery, and 47% after embolization. Poor grade patients had, equally, as well an acceptable as a pour outcome, between 0% and 50%. There was no significant difference between the outcome of surgical or endovascular patients. We conclude that GDC embolization is not associated with a higher risk of morbidity and mortality than open surgery. This risk may even be lower for lesions in surgically unfavorable locations. The GDC technique is a less invasive, effective option to prevent re-bleeding in early stage, even in poor-grade patients. However, these encouraging medium-term results have to be confirmed by a longer observation period.