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Background: The present study evaluates the effectiveness of an ultrasound (US) practice course based on a sheep brain cadaver. Neurosurgical education is considerably restrained following patient safety objections and work time restrictions. It is therefore of vital importance to offer residents an opportunity to practice certain US techniques in a controlled environment without ethical or legal restrictions. We developed an US training model based on a sheep brain cadaver in order to demonstrate the feasibility of such a model, facilitate crucial anatomic knowledge, and demonstrate a learning curve from it., Methods: Over the course of 2 months from December 2012-January 2013, a total of 13 residents took part in a three part training session, each consisting of 20-30 min of individual US-training and performance evaluation based on a biological phantom. The first cadaver was a physiologic sheep brain. After initial familiarization with the US, the residents performed an US on a second cadaveric brain and tried to find a 0.5 cm big (in diameter) echogenic structure. In a third brain they were asked to identify a cyst (Fogarty catheter filled with water)., Results: Thirteen neurosurgical residents participated in the study. After the first training session, the learning curve improved significantly in the second and the third session. The ability to actuate the US device, the time needed to display crucial anatomic landmarks, and to locate the two different artificial masses increased, and respectively decreased remarkably by up to 80%., Conclusion: After 2 months and three training sessions, the handling of the US from the residents was excellent in the operating room. The accuracy and the dexterity in use of the US improved significantly. The participants found the model to be realistic and agreed on the need for further promotion of such courses.

Background: The sylvian fissure (SF) is the anatomical pathway used in a pterional approach, which leads to most aneurysms. There are four different anatomical variants of the SF described. In the present retrospective study the four different categories of the SF were studied in order to evaluate any correlation of these variants to surgical outcome., Methods: Patients treated for intracranial aneurysms by a pterional transsylvian approach during 2003-2012 (N = 237) were included in the study. The SF category was determined by analysis of preoperative computed tomography (CT) scanning. Patients were grouped into unruptured intracranial aneurysms (UIA) and ruptured intracranial aneurysms with subarachnoid hemorrhage (SAH) according to the Hunt and Hess grades. Brain edema, vasospasms, ischemic lesion rate, and outcome were evaluated for possible correlation with SF anatomical variants., Results: Postsurgically brain edema formation correlated significantly with more complex anatomical variants of the SF in patients with UIAs and in patients with Hunt and Hess 1 and 2. Ischemia rate, vasospasms, or clinical outcome was not negatively affected though., Conclusion: The classification of the SF as proposed by Yasargil is more than a pure anatomical observation. In this retrospective study, we show that the anatomical variants of the SF can be associated to postoperative complications like formation of brain edema or ischemic lesions Preoperative knowledge of the SF anatomy and possibly consecutive adapted extend of the surgical approach can decrease procedure-related morbidity.

Objective: International guidelines for the management of unruptured intracranial aneurysms (UIAs) recommend observation in aneurysms <10 mm due to the estimated low risk of rupture. The aim of our study was analyse the data of recently treated patients with ruptured cerebral aneurysms with the special focus on size and configuration in view of the frequency scale in a daily routine setting., Methods: We reviewed the data of all patients with aneurysmal subarachnoid haemorrhage (SAH) during the last 24 months at our institution. Configuration and size of the aneurysms were measured. Clinical data were collected using the following classifications for analysis: Hunt and Hess (H&H), modified Rankin Scale (mRS) and Fisher classification., Results: Data of 135 patients with aneurysmal SAH (98 women, 37 men; ratio 2.6:1) were analysed. Analysis showed that 19 aneurysms (14 %) were >10 mm (mean size, 19.2 mm) and 116 aneurysms (85.9 %) <10 mm (mean size, 6.2 mm). In total, 112 were categorised as berry-like configured aneurysms (n = 113 <10 mm, n = 3 >10 mm), 18 as multi-lobar (n = 16 <10 mm, n = 2 >10 mm) and 5 as fusiform (n = 4 <10 mm, n = 1, >10 mm)., Conclusion: Since the results of our study showed that the majority of the aneurysms are <10 mm (mean, 6.2 mm), it is justified to challenge the recommendations of the international guidelines in a daily routine setting. We believe that the published data are not convincing enough to play a guidance role in daily routine. Due to improving surgical and endovascular techniques with satisfying results and the high number of ruptured small aneurysms, we believe a change in attitude in management of small-sized aneurysms is needed. Further diagnostic models are needed to determine the risk of rupture of intracranial aneurysms properly to obtain adequate treatment for UIAs.

We present the case of a 30-year-old male patient with an almost complete destruction of the calvarial bone through an anaplastic meningioma diagnosed in line with dizziness. Neuroimaging revealed an extensive growing, contrast enhancing lesion expanding at the supra- and infratentorial convexity, infiltrating and destroying large parts of the skull, and infiltrating the skin. Due to progressive ataxia and dysarthria with proven tumor growth in the posterior fossa in the continuing course, parts of the tumor were resected. A surgical procedure with the aim of complete tumor resection in a curative manner was not possible. Six months after the first operation, due to a new tumor progression, most extensive tumor resection was performed. Due to the aggressive and destructive growth with a high rate of recurrence and tendency of metastases, anaplastic meningiomas can be termed as malignant tumors. The extrinsic growth masks the tumor until they reach a size, which makes these tumors almost unresectable. In the best case scenarios, the five-year survival is about 50%. With the presented case, we would like to show the aggressive behavior of anaplastic meningiomas in a very illustrative way. Chemotherapy, radiotherapy, and surgery reach their limits in this tumor entity.

The present study evaluates the incidence of early and late seizures after head injury in patients under 18 years old. Factors correlating with a high risk of developing posttraumatic seizures were identified. Such risk factors were the severity of the head trauma and a Glasgow Coma Scale of 3-8. In contrast to many studies, we observed that the incidence of posttraumatic seizures was significantly higher in patients older than 12 years old (12-16 and 12-18). Most of the late seizures were paroxysmal electroencephalography (EEG) discharges diagnosed on a snapshot-EEG during the follow-up examination of the patients without clinical symptoms. We suppose that EEG-examination in head injured children is important to identify patients with epileptic potentials without clinical symptoms. Epileptic patterns of the EEG could worsen the diagnosis and clinical outcome of the children in accordance to studies performed in the adult population.

Intervertebral fusion through an anterior approach with polymethylacrylate is a well-established neurosurgical technique in the treatment of cervical spine degeneration. However, questions still remain concerning the post-surgical outcome. Factors influencing surgical outcome that could help to predict which patients need further post-surgical treatment and what to expect after surgery are the subject of numerous studies. In the present study, we retrospectively collected data from patients who had undergone intervertebral fusion and defined which pre-operative factors could influence the surgical outcome. Between 1993 and 1997, 379 patients were surgically treated with the ventral fusion technique in our hospital. In 2006, we sent a questionnaire to the patients and 164 responses were received. We identified pre-operative presence of severe pain, hypesthesia, palsy and gait disturbance as negative predictive factors, whereas age, body mass index, pre-operative physical strain and the cervical segment involved did not seem to influence prognosis. In conclusion, identifying pre-operative factors which influence prognosis after intervetebral fusion will help predict postoperative outcome.

Objectives: The aim of this study was to work out the special features of subarachnoid hemorrhage (SAH) of unknown origin in respect of diagnostic evaluation, clinical course, and outcome in a large cohort of patients., Methods: We reviewed the data of 179 patients with SAH of unknown origin during 1991 and 2008. The differentiation between perimesencephalic (PM-SAH) and non-perimesencephalic SAH (NON-PM-SAH) was done under consideration of the bleeding pattern on CT scanning., Results: Among 1226 treated patients with spontaneous SAH over a time period of 17 years, a bleeding source remained undetected on first digital subtraction angiogram (DSA) in 179 patients (16.7%)--47 PM-SAH (26.3%) and 132 NON-PM-SAH (73.7%). The clinical signs of patients with PM-SAH were less marked compared to those with NON-PM-SAH, equally to the Hunt and Hess grade. magnetic resonance imaging (MRI) and MR angiography had 100% negative findings for non-aneurismal bleeding sources in all patients. Second DSA revealed a bleeding source in the NON-PM group in 10.8%. The clinical course of the patients with NON-PM-SAH showed a significantly higher rate of complications and a mortality of about 10%. The outcome was excellent in the PM group, in contrast to a fatal course in 13 cases in the NON-PM group., Discussion: PM-SAH imposed with a mild clinical course and an excellent outcome, without severe complications. In contrast to this, NON-PM-SAH has a significant higher rate of dreaded complications and mortality. It is crucial to make an exact diagnosis of PM-SAH, considering CT scanning during the first 24 hours after occurrence of symptoms and the radiological features.

Objective. The aim of our prospective study was to investigate the applicability and the diagnostic value of near-infrared spectroscopy (NIRS) in SAH patients using the cerebral oximeter INVOS 5100C. Methods. Measurement of cerebral oximetry was done continuously after spontaneous SAH. Decrease of regional oxygen saturation (rSO(2)) was analyzed and interpreted in view of the determined intrinsic and extrinsic factors. Changes of rSO(2) values were matched with the values of ICP, tipO(2), and TCD and the results of additional neuroimaging. Results. Continuous measurement of rSO(2) was performed in nine patients with SAH (7 females and 2 males). Mean measurement time was 8.6 days (range 2-12 days). The clinical course was uneventful in 7 patients without occurrence of CVS. In these patients, NIRS measured constant and stable rSO(2) values without relevant alterations. Special findings are demonstrated in 3 cases. Conclusion. Measurement of rSO(2) with NIRS is a safe, easy to use, noninvasive additional measurement tool for cerebral oxygenation, which is used routinely during vascular and cardiac surgical procedures. NIRS is applicable over a long time period after SAH, especially in alert patients without invasive probes. Our observations were promising, whereby larger studies are needed to answer the open questions.

Purpose: We demonstrate clinical features, therapy and outcome of 14 patients with symptomatic spinal cavernous malformations (CM)., Methods: We retrospectively reviewed all patients who underwent microsurgical treatment of symptomatic spinal CM during the last decade in our department through an analysis of our database., Results: We analyzed the data of 14 patients (11 females, 3 males) with symptomatic spinal CM in a range of 16-77 years (mean age 47.8 years). Seven patients (50%) experienced significant improvement of their symptoms rapidly after surgery. The remaining seven patients presented new non pre-existing complaints, which improved gradually with a favourable outcome at the last follow-up examination in six cases., Conclusion: Microsurgical treatment under perioperative electrophysiological monitoring is justified to prevent severe neurofunctional deterioration in symptomatic spinal CM. Although some of the patients deteriorate after surgery, the symptoms are rapidly declining with a favourable outcome in majority of them.

Background: Three-dimensional (3D) angiography is increasingly used in the diagnostics of brain aneurysms. Aim of the present study was to evaluate the accuracy of 3D angiograms with respect to its value for preoperative planning of aneurysm clipping., Patients and Methods: The 3D angiograms of 42 patients with subarachnoid bleeding caused by aneurysm rupture of the anterior circle of Willis and the intradural carotid have been compared to intraoperative photographs of the aneurysms., Results: Neighbouring vessels, aneurysm anatomy, arteries originating from the aneurysm wall were accurately shown decreasing the surgical risk of aneurysm clipping., Conclusions: The 3D images enabled a perfect preoperative planning through the operation by illuminating the aneurysm anatomy, neck localisation and shape and relation of the aneurysm to neighbouring vessels. Operative approach, use of an accurate clip and avoidance of clipping arteries close to the aneurysm have become predictable and safer by the use of 3D angiography.

Object: The aim of this study was to evaluate the diagnostic value of MR imaging in perimesencephalic (PM) and nonperimesencephalic (non-PM) subarachnoid hemorrhage (SAH) of unknown origin., Methods: The authors conducted a retrospective review of all patients with SAH (1226 patients) in their department between January 1991 and December 2008. Included in the study were cases of spontaneous SAH diagnosed using CT scans obtained within 24 hours of the initial symptoms and initially negative digital subtraction (DS) angiograms. Patients with traumatic SAH and an unknown history were excluded from the study. Patients with initially negative DS angiograms were divided into 2 groups: Group 1, a typically PM bleeding pattern (PM SAH); and Group 2, a non-PM bleeding pattern (non-PM SAH) such as hemorrhage in the sylvian or interhemispheric fissure. Cranial MR imaging including the craniocervical region was performed within 72 hours after SAH was diagnosed in all patients in Groups 1 and 2., Results: One thousand sixty-eight patients underwent DS angiography, and among them were 179 (16.7%) with negative angiograms--47 patients (26.3%) from Group 1 and 132 patients (73.7%) from Group 2. Magnetic resonance imaging demonstrated no bleeding sources in any case (100% negative). Thirty-four patients in Group 1 and 120 patients in Group 2 underwent a second DS angiography study. Digital subtraction angiography revealed an aneurysm as the bleeding source in 1 case in Group 1 and in 13 cases in Group 2., Conclusions: Magnetic resonance imaging of the brain and craniocervical region did not produce additional benefit for the detection of a bleeding source and the therapy administered for PM SAH and non-PM SAH (100% negative). The costs of this examination exceeded the clinical value. Despite the results of this study, MR imaging should be discussed on a case-by-case basis because rare bleeding sources are periodically diagnosed in cases of non-PM SAH. A second-look DS angiogram is necessary because aneurysmal hemorrhage occasionally produces PM SAH as well as non-PM SAH. Further prospective studies are needed to verify the authors' results in the future.

To demonstrate clinical characteristics of symptomatic spinal metastases of intracranial glioblastoma multiforme (GBM) and different spreading mechanisms relating to astrocytic cell differentiation, we present an extraordinary case of a 47-year-old patient with rapid progressive paraplegia due to coincident intramedullary and leptomeningeal dissemination of a supratentorial GBM. Serial biopsies of the intracranial, leptomeningeal, and intramedullary GBM lesions of our patient were analyzed for glial fibrillary acidic protein (GFAP). Furthermore, we present 19 additional cases of intracranial GBM with symptomatic spinal seeding, identified through literature review. GFAP expression was high in intracranial and intramedullary tumors, but low in leptomeningeal dissemination of our patient. Mean patient age was 45 years. Mean interval between identification of spinal metastases and death was 4.5 months. Mean overall survival was 18.6 months. Location of symptomatic spinal metastases was more frequently leptomeningeal (14 cases) than intramedullary (7 cases). The case presented herein supports the hypothesis of higher incidence of low GFAP expression in GBM cells in leptomeningeal manifestations after primary intracranial GBM. Because of the proposed tendency for early leptomeningeal spread from primary tumors with low astrocytic differentiation (low GFAP expression), patients with these tumors should be followed more closely to identify leptomeningeal tumor progression early on. Early identification of leptomeningeal spread could enable these patients to benefit from radiation therapy before they develop severe neurological deficits, which might translate into longer acceptable quality of life for these mostly young patients. This is an important finding, but further prospective studies are needed to verify our observations.

Background: Spontaneous subarachnoid hemorrhage (SAH) without evidence of a bleeding source on the first digital subtraction angiogram (DSA) - also called SAH of unknown origin - is observed in up to 27% of all cases. Depending on the bleeding pattern on CT scanning, SAH can be differentiated into perimesencephalic (PM-SAH) and non-perimesencephalic SAH (NON-PM-SAH). The aim of our study was to investigate the effectiveness of magnetic resonance imaging (MRI) for detecting a bleeding source in SAH of unknown origin., Methods: We retrospectively reviewed 1,226 patients with spontaneous SAH between January 1991 and December 2008 in our department. DSA was performed in 1,068 patients, with negative results in 179 patients., Results: Forty-seven patients were categorized as having PM-SAH and 132 patients as having NON-PM-SAH. MRI of the brain and the craniocervical region was performed within 72 h after diagnosis of SAH and demonstrated no bleeding sources in any of the PM-SAH and NON-PM-SAH patients (100% negative)., Conclusions: In our experience MRI did not produce any additional benefit for detecting a bleeding source after SAH with a negative angiogram. The costs of this examination exceeded the clinical value. Despite our results MRI should be discussed on a case-by-case basis because rare bleeding sources are periodically diagnosed in cases of NON-PM-SAH.

Objective: Lung protective ventilation has a beneficial effect in treating patients with acute respiratory distress syndrome (ARDS). An effect of this ventilation modality is hypercapnia, which leads to increased cerebral blood flow. Since increased cerebral blood flow can induce brain oedema the question arises whether lung protective ventilation can be applied in patients with subarachnoid haemorrhage., Methods: We retrospectively analysed 12 patients with subarachnoid haemorrhage who were ventilated with lung protective ventilation since they suffered of ARDS. Tidal volume was 5-8 ml/kg body weight, and positive end expiratory pressure was 10-15 cm H₂O. Intracerebral pressure was continuously measured by intracerebral probe., Results: Despite of hypercapnia (pCO₂ 50-60 mmHg) there was no increase of the intracerebral pressure. Lung protective ventilation could be safely performed in patients with subarachnoid haemorrhage., Conclusion: Patients with higher Hunt and Hess grades of subarachnoid haemorrhage who are predominantly intubated and ventilated and most of them suffer from ARDS can receive lung protective ventilation. In our small patient collective, the occurring hypercapnia did not influence (increase) the intracerebral pressure.

Glioblastoma multiforme (GB) is the most common and most malignant primary intracranial tumor. Of the 577 patients who underwent surgery for newly diagnosed GB (World Health Organization grade IV) between January 1991 and March 2008 at our department, seven had infratentorial GB (iGB) (incidence 1.2%). Patients younger than 21years of age, as well as patients with gliomatosis cerebri, were excluded from the analysis. We concluded that iGB is rare in adults. Because of its rarity and the non-specific radiological features of iGB, it can easily be misdiagnosed as a brain metastasis, ependymoma or even as a benign lesion such as vestibular schwannoma or meningioma. Surgical removal, or at least stereotactic biopsy, is essential to establish the diagnosis. Postoperative adjuvant therapy similar to that for supratentorial glioblastoma is indicated. We analysed the clinical characteristics and therapy of our patients with iGB and reviewed the literature., (Copyright 2010 Elsevier Ltd. All rights reserved.)

We present a case of dorsal cervical spinal cord injury in a 16-year-old boy caused by a screwdriver. Neurological deficits were hypaesthesia of the right body and neurovegetative functional deficits. Magnetic resonance imaging showed significant myelopathy and a subdural haematoma of the cervical spine. Surgical treatment was not necessary. Rheological infusions, lumbar puncture and rehabilitation resulted in full neurological recovery.