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Background: Proton magnetic resonance spectroscopy (1H MRS) constitutes a promising modality to assess intracranial pathology. We present our experience using this method in grading solid brain astrocytomas. Material and Methods: Using a 1.5-Tesla MRI unit, 71 patients with the radiographic diagnosis of astrocytoma were examined. Water-suppressed single-voxel 1H MRS was employed in all of our patients. The concentrations of choline (Cho), N-acetyl-aspartate (NAA), phosphocreatine-creatine (Pcr-Cr), myo-inositol (MI), lactate (Lac), lipids (Lip) as well as the metabolite ratios of Cho/Pcr-Cr, NAA/PCr-Cr and NAA/Cho were calculated. An appropriate surgical biopsy was performed. Standard pathology examination was employed in a double-blinded fashion. Results: An increased concentration of Cho and decreased concentrations of Pcr-Cr and NAA were detected. The concentrations of Lac, Lip and MI varied inconsistently, even among tumors of the same histologic grade. The Cho/Pcr-Cr ratio was calculated. This ratio was found to be 2.15 ± 0.26 in 27 patients with astrocytomas grade I and II, 2.78 ± 0.09 in 18 patients with grade III, and 5.40 ± 0.16 in 26 patients with grade IV. Discussion: The increased concentration of Cho is due to the increased cellularity and a relatively increased number of membranous structures in highly malignant tumors. In abnormal anaerobic metabolic tumor states there is relatively less phosphorylization of creatine. By using the Cho/Pcr-Cr ratio the concomitant effects of structural and metabolic alteration can thereby be emphasized for diagnostic advantage. Conclusion: The Cho/Pcr-Cr is a very important and statistically significant marker (p = 0.043) determining the degree of intracranial astrocytoma malignancy.

Central venous catheters are essential in the medical management of critically ill pediatric patients. Medical practitioners should be aware of the potential for misplacement of these devices as such complications may result in serious injury and possible death. Catheter malpositioning is not limited to any particular site and may have far-reaching consequences that affect a single or multiple organ systems. We present two cases where central venous catheter positioning led to complications that resulted in intracranial pathology which was fatal in one case.

Two cases of chronic subdural haematoma following a snowboard head injury are reported. Although such cases are rare in sport, the risk in snowboarders is higher than expected. Evaluation of a snowboarder with a history of head injury, albeit mild, who complains of headaches should include computed tomography or magnetic resonance imaging to allow rapid identification of any intracranial pathology.

In this retrospective clinical study, 20 patients were identified to have atypical positional nystagmus associated with positional vertigo following a thorough history and otoneurologic examination. All patients underwent either computed tomography or magnetic resonance imaging. Eight patients demonstrated radiologic evidence of intracranial pathology; the majority had clinical findings suspicious for central pathology. Of 12 patients with normal intracranial imaging, none had a history or clinical findings suspicious for central pathology. The results of this study suggest that in the absence of clinical findings suspicious for central pathology, atypical positional nystagmus in isolation does not necessarily need to be investigated for central lesions. Clinical review of this patient population, however, is required to determine if there is resolution or evaluation to a recognizable form of inner ear dysfunction.

General Part: 1. Imaging Methods: 1.1. Color Doppler Ultrasonography of the Eye and Orbit (W. Lieb). 1.2. Computer Tomography (W.S. Muller-Forell and W. Wichmann). 1.3. Magnetic Resonance Imaging (W. Wichmann and W.S. Muller-Forell).- 2. Anatomy of the Visual System (W.S. Muller-Forell and W. Wichmann).- 3. Neuroophthalmology. A Short Primer (U. Schwarz).- 4. Functional Magnetic Resonance Imaging (fMRI) of the Human Visual System (S.S. Kollias).- Special Part: 5. Optical Pathway Pathology in Children (E. Bolsthauser and E. Martin).- 6. Orbital Pathology (W.S. Muller-Forell and S. Pitz).- 7. Intracranial Pathology of the Optic Pathway (W. Muller-Forell).- Subject Index.- List of Anatomic Structures.- List of Abbreviations.- List of Contributors.

Bu çalışma, 2001 yılında Antalya'da düzenlenen Conference on Research and Publishing Neurosurgery'da bildiri olarak sunulmuştur. There is no comprehensive and reliable model available in small animals that are suitable for the study of subarachnoid haemorrhage (SAH). In the study we reviewed the advantages and disadvantages of available SAH models in rats and presented our model. Experimental SAH was induced in a group of 350-450 g SpragueDawley rats. A 2 mm-diameter burr hole was drilled and, working under a microscope, haemorrhage was produced by transclival puncture of the basilar artery with a 20 mum thick piece of glass. The rats were assigned to either the experimental group (n: 7) or the control group (n: 7). Local cerebral blood flow (LCBF), intracranial pressure (ICP), and cerebral perfusion pressure (CPP) were measured for 60 min after SAH, after which the rats were decapitated. Microscopic examinations were done on three different segments of the basilar artery. There was a significant and sharp drop in LCBF just after SAH was induced (56.17 +/- 12.80 mILD/min/100 g and 13.57 +/- 5.85 mILD/min/100 g for baseline and post-SAH, respectively; p < 0.001), the flow slowly increased by the end of the experiment but never recovered to pre-SAH values (43,63 +/- 7.6 mILD/min/ 100 g, p < 0.05). ICP (baseline 7.33 +/- 0.8 mmHg) increased acutely to 70.6 +/- 9.2 mmHg, and also returned to normal levels by 60 min after SAH. CPP (baseline 75.1 +/- 4.9 mmHg) dropped accordingly (to 21.0 +/- 6.3 mmHg) and then increased, reaching 70.1 +/- 4.9 mmHg at 60 min after SAH. Examinations of the arteries revealed decreased inner luminal diameter and distortion of the elastica layer. We present an inexpensive and reliable model of SAH in the rat that allows single and multiple haemorrhages and to study the early and late course of pathological changes. European Association of Neurosurgical Societies

The transfacial access osteotomies that are discussed in this chapter are not intended for use in treatment of malignant sinus neoplasms that have invaded the skull base. Such tumors require radical resections that frequently produce unavoidable disfigurement and dysfunction. Instead, these osteotomies are designed to maintain form and function of the facial skeleton and overlying soft tissues. They provide wider and more direct access to less aggressive tumors involving relatively inaccessible areas of the skull base itself or beyond to intracranial pathology while reducing or eliminating the need for traction on the brain, brainstem, or cranial nerves. These approaches must be thought of in terms of a surgical funnel, the mouth of which is located at the level of the superficial projections of the facial skeleton and the spout at the skull base. Although the spout size will be increased only slightly or not at all, the mouth of the standard transoral, transnasal, transfrontal, and transtemporal approaches to the skull base will be greatly widened. Thus the working distance from the surgeon’s hands to the skull base or intracranial target will be shortened, but the field view angle will be maintained or increased (Figure 45.1).

The development of de novo intracranial aneurysms following stereotactic radiosurgery for intracranial pathology is a rare complication secondary to vascular injury. Typically, these aneurysms develop within the first few years after radiation surgery. We present the first case of an aneurysm developing 10 years after radiosurgery for a cerebellopontine angle meningioma. This case highlights the importance of careful long-term follow-up of patients who undergo radiosurgery for lesions abutting major vessels and/or who suffer post-radiation complications.

Forensic medicine and neuropathology not infrequently come together in the investigation of cases of sudden death, which in a small but significant number of instances is due to intracranial pathology rather than cardiovascular disease. Clinical information may help to provide the cause of an unexpected death but may be absent in circumstances that are unexplained.

An overview of current understanding of the vasospasm that occurs days after SAH is provided with the primary purpose being to highlight some areas where a more rigorous scientific understanding of the processes involved is required.

We report a 4 year old girl with ring enhancing lesions in brain CT, initially diagnosed as neurocysticercosis but did not respond to cysticidal therapy. A Magnetic resonance spectropscopy (MRS) revealed lipid peaks suggestive of tuberculoma which was successfully treated with antituberculosis therapy. This report highlights the role of MRS in the diagnosis of ring enhancing lesios.

Since its inception (Hounsfield, 1973), computerised tomography (CT) has become an invaluable diagnostic and research tool, particularly in clinical neurology and neurosurgery. Clinically, CT has proved useful in differentiating between ‘functional’ and ‘organic’ psychiatric disorders where it is particularly helpful in the diagnosis of potentially treatable organic disorders. For example, Owens et al (1980) found clinically unsuspected intracranial pathology in 12 of 136 chronic schizophrenic patients examined by CT and Roberts & Lishman (1984) found diagnosis, management, and/or prognosis were influenced in approximately 12% of cases referred by psychiatrists for CT imagining.

We report two patients with severe radiculopathy due to elevated intracranial pressure (ICP) resulting from idiopathic intracranial hypertension (IHH) in one, and cerebral venous sinus thrombosis (CVT) in the other. Our aim is to document this unique association, which escaped diagnosis in both patients.

A retrospective case note review of head injuries in neonates admitted to the Neonatal Surgical Unit in Glasgow between 1990 and 1996 (n=25) was carried out. Most injuries were caused by a fall (68%) and resulted in scalp haematomata and associated skull fractures in the majority of patients. Three neonates were involved in high speed road traffic accidents, and these infants all had intracranial pathology identified by computed tomography. Isolated skull fractures were common and did not appear to be associated with any neurological deficit. Non-accidental injury was uncommon in this age group. Outcome was excellent in the majority of patients (92%).

This study aimed at the investigation of release patterns of neuron specific enolase (NSE) and protein S-100B after traumatic brain injury (TBI) and their association with intracranial pathologic changes as demonstrated in computerized tomography (CT). We analyzed NSE and S-100B concentrations in serial venous blood samples taken one to three days after TBI in 66 patients by the use of immunoluminometric assays. These markers are considered to be specific neurobiochemical indicators of damage to glial (S-100B) or neuronal (NSE) brain tissue. Standardized neurological examination and plani- and volumetric evaluation of computerized tomography scans were performed in all patients. Patients with medium severe to severe TBI [Glasgow Coma Scale (GCS) score at the site of accidentor =12] exhibited significantly higher NSE and S-100B concentrations and a significantly longer release compared to patients with minor head injury (GCS: 13-15). Both, patients with and without visible intracerebral pathology in CT scans exhibited elevated concentrations of NSE and S-100B after TBI and a significant decrease in the follow-up blood samples. Release patterns of S-100B and NSE differed in patients with primary cortical contusions, diffuse axonal injury (DAI), and signs of cerebral edema (ICP) without focal mass lesions. All serum concentrations of NSE and S-100B were significantly correlated with the volume of contusions. The data of the present study indicate that the early release patterns of NSE and S-100 may mirror different pathophysiological consequences of traumatic brain injury.

Pupillometry has been widely employed in the evaluation of a large number of pathological conditions, including intracranial pathology. The recent introduction of a portable, user-friendly, infrared pupillometer (ForSite, NeurOptics Inc., Irvine, CA) has enabled the accurate and reproducible measurement of several pupillary parameters, such as maximum and minimum apertures, constriction and dilation velocities, and latency period. It should be noted that various clinical conditions, especially neurological and ocular diseases, as well as numerous medications, may interfere with the measurements. Furthermore, a number of physiological parameters, such as the intensity of retinal illumination, the level of patient's alertness, the intensity of ambient light, as well as the time of day that the examination is performed may alter the obtained values. The potential implications of pupillometry in the clinical assessment of neurosurgical patients, including its complex relationship to intracranial pressure changes, mandate the undertaking of prospective clinical studies validating the clinical significance of this noninvasive, diagnostic modality.

OBJECTIVE: Intractable singultus is a rare but significantly disruptive clinical phenomenon that often accompanies other diseases but can present in isolation due entirely to intracranial pathology. We report a case of intractable singultus that improved after microvascular decompression and present a comprehensive review of singultus by discussing its similarity to other cases of microvascular decompression, its history and etiology, and its evolutionary basis. CLINICAL PRESENTATION: The patient exhibited intractable singultus for 15 years, resistant to multiple medical regimens. INTERVENTION: Microvascular decompression to relieve pressure on the tenth cranial nerve and medulla oblongata resulted in near total resolution of the singultus. CONCLUSION: Neurovascular compression should be considered a potentially reversible cause of intractable singultus, a significantly disabling clinical phenomenon.

Pseudotumour cerebri is a clinical syndrome characterized by increased intracranial pressure in the absence of intracranial pathology. The possible association between this condition and infections has already been mentioned in a few case series. This paper describes a 6-y-old girl with a classical picture of pseudotumour cerebri which developed 1 week following varicella. To the authors' knowledge, this is the first description suggesting this association. Additional reports are required to support the possible relationship between the two conditions.

Computerized tomography (CT) continues to be extensively utilized to exclude intracranial pathology in psychiatric practice, but little is known about clinical risk factors, which might predict those patients most likely to benefit from the procedure. We reviewed 150 cases of psychiatric patients who received CT scans to exclude intracranial pathology. We assessed the relationships of patient age, psychiatric diagnosis, and findings from neurologic and cognitive examinations to CT results that influenced patient care, and overall normal and abnormal CT results. Fifty-three percent of the CT scans were abnormal, 11% influenced patient care, and only 2% identified potentially reversible lesions. Cognitive exam results and, to a lesser extent, neurologic exam results, were sensitive predictors of CT findings that influenced patient care. All patients with clinically influential CT results had cognitive deficits and all but one had neurologic deficits. Patients older than 60 years of age and those with organic mental syndromes were most likely to have clinically influential CT findings. Our results suggest that utilizing specific clinical risk factors such as findings from clinical examinations, patient age, and psychiatric diagnosis, to guide the ordering of CT scans, can greatly increase the yield of the procedure for psychiatric patients, without excess medical morbidity.

We have used craniofacial access in 20 children (age range 3/12–14 years) for complex skull base/intracranial pathology over the past 5 years. The majority of the patients had a tumour – 7 of the skull base, 5 extensive suprasellar lesions and 3 acoustic neuromas; 4 had an aneurysm or AVM and in 1 there was a congenital problem. This extended application of established adult techniques in a paediatric practice emphasises the fundamental point that the quintessence of good surgical practice is the construction of an operation for the individual patient's pathology. We therefore used transzygomatic, orbital, transoral, transmandibular, petrous, transcondylar, translabyrinthine and transbasal access techniques. Good function and cosmesis with minimal complications were achieved. We have not observed complications with craniofacial growth and the majority of patients were able to return to normal school. The range of approaches used emphasise the importance of a multidisciplinary team with both paediatric and neurosurgical expertise, especially with complex vascular and skull base pathology, in dealing with these difficult problems. The case for specialist referral merits some discussion within the representative bodies of paediatric neurosurgeons.

Intracerebral Hemorrhage (IH) is an important cause of secondary brain injury in neurosurgical patients. Early identification and treatment improve neurologic outcome. We have tested Near Infrared Spectroscopy (NIRS) as an alternative noninvasive diagnostic tool compared to CT-Scans to detect IH. We prospectively studied 212 patients with neurologic symptoms associated with intracranial pathology before performing a CT-scan. NIRS signals indicated pathologies in 181 cases (sensitivity 0.96; specificity 0.29). In a subgroup of subdural hematomas NIRS detected 45 of 46 hematomas (sensitivity 0.96; specificity 0.79). Identification of intracerebral hemorrhage using NIRS has the potential to allow early treatment, thus possibly avoiding further injury.© (1998) COPYRIGHT SPIE--The International Society for Optical Engineering. Downloading of the abstract is permitted for personal use only.

Objective:In many countries, neurosurgical care is concentrated in regional centres, which often necessitates the inter-hospital transfer of patients with head injury for optimal treatment. The aim of this study was to evaluate the role of teleradiology in the management of head-injured patients when referred from a district general hospital to a tertiary neurosurgical centre.Methods:Prospective data were collected over a fifteen month period from March '95 to May '96. Head-injured patients referred without the facility of teleradiology (Group 1), were compared to similar patients referred with teleradiologie images (Group 2), with particular regard to therapeutic intervention before transfer and adverse events during transfer.Results:There were 28 patients in Group 1 and 35 in Group 2, of which 31 were transferred. Both groups were comparable with respect to age, admission Glasgow Coma Scale score, and intracranial pathology. For patients transferred with teleradiology consultation (Group 2), therapeutic interventions were more (32.1% vs. 10.7%, p = 0.06), adverse events during transfer were significantly lower (6.4% vs. 32.1%, p = 0.01), and transfer time was reduced (72 vs. 80 minutes, p = 0.38). Four patients in Group 2 were treated by a mobile neurosurgical team at the referring hospital because of rapid clinical deterioration.Conclusion:Our findings indicate that teleradiology has an important role in improving inter-hospital management of head-injured patients.

Recent advances in neuroimaging, particularly the magnetic resonance imaging (MRI) scan, have greatly enhanced our ability to visualize intraparenchymal anatomy. With the linkage between intracranial pathology and epilepsy now clearly established, the MRI data provides detailed information for the clinician treating patients with epilepsy. This article supplies the reader with an overview of the new techniques in MRI brain imaging that allow us to identify intracranial abnormalities, and a survey of some of the MRI-identified substrates of epilepsy.

Purpose Sometimes, intracranial pathology in the distal vasculature cannot be accessed by standard endovascular techniques because of occlusion or insurmountable tortuosity of theinternal carotid artery (ICA). A trans-sphenoidal surgical approach can follow a similar trajectory to the course of the supraclinoid ICA. This study evaluates the feasibility of a trans-sphenoidal approach to the supraclinoid ICA for endovascular access. Materials and Methods In a fresh cadaver head, the sphenoid sinus was dissected through a trans-sphenoidal route. Bone over the carotid prominence was removed to expose the ICA. The artery was catheterized using the Seldinger technique, and three-dimensional digital subtraction angiography was performed to evaluate the procedure. Results The catheter was successfully inserted into the supraclinoid ICA via the trans-sphenoidal route. Three-dimensional radiographic reconstruction confirmed placement of the catheter and the trajectory of the sheath into the supraclinoid ICA. Conclusion While the trans-sphenoidal route has innumerable disadvantages over the standard endovascular access techniques, this route could be considered when other treatment options are too risky or impractical.

The aim of this study was to characterize intracranial tumors based on MR measurements of regional cerebral blood volume. In 8 patients without intracranial pathology and 42 patients with intracranial tumors a T2*-weighted image series was acquired during bolus injection of gadolinium-DTPA, and regional cerebral blood volume maps were calculated. The regional cerebral blood volume index (rCBVi) of vital tumor was expressed in percent of the value measured in contralateral gray matter. In extra-axial tumors (meningiomas) rCBVi was higher (124 ± 110%), and in low-grade intra axial tumors rCBVi was lower (79 ± 65%), than in contralateral cortex. In malignant intra-axial tumors the distribution of rCBV was heterogenous: high in vital tumor (glioblastomas: rCBVi = 165 ± 85%; metastases: rCBVi = 106 ± 79%), but low in necrosis (rCBVi = 33% of contralateral white matter) and edema (rCBVi = 53% of contralateral white matter). rCBVi was highest in arteriovenous malformations (1053 ± 584% of contralateral gray matter). We conclude that the regional cerebral blood volume distribution is useful to characterize intracranial tumors, although the large biological variability of individual tumor entities indicates limitations.

Benign intracranial hypertension is a condition of obscure aetiology which presents with episodic headaches and nausea. It is a diagnosis based on the exclusion of other intracranial pathology and computed tomography is usually normal. We present a case of gliomatosis cerebri which was initially diagnosed and treated as benign intracranial hypertension.

We report a retrospective study to determine the cost‐effectiveness of cranial computed tomogrsphy in patients with headache without neurological finding. Five hundred ninety‐two neurologically normal patients were examined between 1990 and 1993 for the complaint of headache. Examination results were reevaluated from written report and image archive systems. Results were divided into three groups. In group P0, we included patients with normal cranialcomputed tomography findings. In group P1, patients showed some minor pathologies like ischemic or atrophic changes. These findings neither explained the reason for headache nor changed the clinical or therapeutic approach. The third group (P2) was to include patients with gross intracranial pathology like space‐occupying lesions or bleeding. Five hundred forty‐six of 592 patients were in the P0group (92%), and the remaining 46 patients were in the P1group (8%). No patient was found to have serious intracranial pathology detected by computed tomography. Cost of detection of a case with significant pathology was calculated. It is our opinion that computed tomography is an unrewarding technique in the evaluation of patients with chronic headache whose neurological examinations are normal. Copyright © 1995, Wiley Blackwell. All rights reserved

Magnetization transfer suppression (MTS) pulse was applied to a T1-weighted sequence and compared to the same sequence without MTS in order to detect its effect on gadolinium-enhancing intracranial pathology in children.

Physicians in Emergency Medicine, Pediatric Neurology, and Radiology at Children’s Hospital Boston, MA studied the risk of intracranial pathology requiring immediate intervention among patients presenting in the ED with a first complex febrile seizure (CFS).

We report the case of an 18-year-old male with a vascular-type headache occurring 3 days after a minor closed-head injury. The headache resolved completely, without recurrence, with a single dose of intravenous chlorpromazine. This case and the few others reported in the literature illustrate that the response of a headache to antimigraine therapy cannot be relied upon to diagnose or confirm a diagnosis of migraine headache, or to rule out other intracranial pathology.

In the pathogenesis of neonatal intracranial pathology and adverse neurologic outcome, severe instability of the neonatal cerebral circulation might play an important role. To examine this hypothesis the relationship was explored between intracranial pathology as detected by neurosonography during the first week of life, changes in cerebral blood flow velocity (CBFV) as measured by Doppler ultrasound in the same period and neurologic outcome, as measured by standardized tests during the first year of life. A group of 128 infants born after a pregnancy duration between 25 2/7 and 32 6/7 weeks was studied. In 40% of the infants, the time of occurrence of both types of intracranial pathology was within 1 hour after birth. No relation could be demonstrated between this occurrence and CBFV. Also after the appearance of intracranial pathology no specific changes in CBFV were seen. CBFV was associated with neurological outcome at term age. However, CBFV did not predict outcome of neurological examination at 6 and 12 months of corrected age. Intracranial hemorrhages were associated with abnormal neurological outcome at all assessments. Ischemic lesions were only associated with adverse outcome at 12 months of age.

The mechanism involved in the relative preservation of the subcortical U-fibers in the arcuate zone was studied in a post infarct edema after sagittal superior sinus occlusion.

Endoscopy of the intracranial space requires a new understanding of the anatomy and pathology of pertinent structures. This meets with the new development of imaging methods which equally require three dimensional interpretation of intracranial pathology. The stereological arrangement of intracranial lesions is examplified on three neuropathological conditions: brain tumours, territorial infarction and mass displacement.

The relationship between catch-up head growth and motor performance was examined in 48 very-low-birthweight (< 1,500 g) infants. All infants were nonasphyxiated, normocephalic, and appropriately grown for gestational age at birth. Serial cranial ultrasonography during the first month of life revealed no intracranial pathology. The age of catch-up head growth, defined as the corrected age when the head circumference recovered to the 5th percentile, was determined for each infant. At 12 months corrected age, the infants were evaluated and grouped according to normal (n = 37) or abnormal (n = 11) motor assessments. The abnormal group achieved catch-up head growth by 7.7 ± 2.1 months vs 3.7 ± 3.1 months for the normal group (P< .05). Only 27% of the motor-delayed infants achieved catch-up head growth by 6 months corrected age, as compared with 89% of the normal infants (P< .05). Premature infants who have achieved catch-up head growth by 6 months corrected age, corresponding to the period of maximal postnatal brain growth, have fewer motor abnormalities than infants who attain catch-up head growth later. There is a significant relationship between head circumference at 6 months corrected age and motor development in very-low-birthweight infants.

Cerebrospinal fluid (CSF) dynamics and intracranial pressure-volume relationships can be studied by a wide variety of procedures in clinical settings. Although infusion methods are considered to give better estimates of the resistance to outflow of the CSF (Rout), the technique described by Marmarou et al. [4] is attractive because it is relatively simple, fast and reliable. By the bolus test, we can, by a single procedure, calculate the pressure volume index (PVI), Rout and the compliance of the craniospinal axis (Ccsf). Nevertheless, the value of this procedure in studying patients with suspected abnormal CSF hydrodynamics and especially in selecting patients for shunting in so-called “Normal pressure hydrocephalus” has been rather controversial. One of the problems when trying to define normal CSF dynamics is the lack of normal control values. The present study was undertaken to determine normal PVI, Rout and Ccsf in adults without intracranial pathology.

It is well known that the pulse pressure (PP) of the intracranial pressure pulse wave increases with rising intracranial pressure (ICP). However, the PP at the same ICP value is not always identical in various intracranial pathologies. The present study was performed to clarify the changes of PP with alterations in intracranial components (water content of brain tissue, blood and cerebrospinal fluid).

IntroductionBiochemical markers may have a role to play as objective tools for ruling out significant complications following minor head injury, while reducing the rate of ‘unnecessary’ CT scans. This study aimed to systematically identify and analyse the data from studies investigating biochemical markers as a screening tool for intracranial injury on CT.MethodsPotentially relevant studies were identified by an electronic search of key databases including MEDLINE, EMBASE and CINAHL. Papers in English were included if they consisted of a cohort of more than 20 patients with more than 50% having suffered a minor head injury (GCS 13–15). Studies must describe the use of a biochemical marker to screen for the identification of intracranial or neurosurgical injury.ResultsA total of 7800 citations were identified of which 13 were included. Ten of these were investigating the role of protein S100B, two Neuron-Specific Enolase and one for dopamine and epinephrine. No useful, validated data could be extracted from the non-S100B studies. Mild head injury (GCS of 13–15) was generally consistently defined and included mild symptoms. All recruited patients received the reference standard of CT scan, mostly within 6 h of injury, along with the index test. Analysis techniques varied but are now practical for real-time results in the ED. Meta-analysis of these pooled data gives a sensitivity of 97.7% (95% CI 95.1% to 99.3%) and specificity of 43.4% (95% CI 31.4% to 56.2%) with a negative likelihood ratio of 0.053 (95% CI 0.015 to 0.117).DiscussionThere is a mounting body of evidence to support the addition of protein S100B as a triage tool for CT, in minor head injury patients, within 4 h of their injury. While the quality of studies so far is good, results are mixed and the marker needs further testing in conjunction with clinical decision rules.

The adjacency of intracranial pathology to canonical regions of eloquence has long been considered a significant source of potential morbidity in the neurosurgical care of patients. Yet, several reports exist of patients who undergo resection of gliomas or other intracranial pathology in eloquent regions without adverse effects. This raises the question of whether anatomical and intracranial location can or should be used as a means of estimating eloquence. In this review, the authors systematically evaluate the factors that are known to affect anatomical-functional relationships, including anatomical, functional, pathology-related, and modality-specific sources of variability. This review highlights the unpredictability of functional eloquence based on anatomical features alone and the fact that patients should not be considered ineligible for surgical intervention based on anatomical considerations alone. Rather, neurosurgeons need to take advantage of modern technology and mapping techniques to create individualized maps and management plans. An individualized approach allows one to expand the number of patients who are considered for and who potentially may benefit from surgical intervention. Perhaps most importantly, an individualized approach to mapping patients with brain tumors ensures that the risk of iatrogenic functional injury is minimized while maximizing the extent of resection.

Introduccion. Las arterias cerebrales anteriores son ven afectadas con frecuencia por el vasoespasmo secundario a hemorragia subaracnoidea. La eficacia del ultrasonido Doppler transcraneal para detectar esta complicacion no se ha determinado con exactitud. Objetivo. Comprobar la utilidad del ultrasonido Doppler transcraneal para diagnosticar el vasoespasmo de las arterias cerebrales anteriores en pacientes con hemorragia subaracnoidea. Pacientes y metodos. Estudiamos 56 pacientes entre los dias 4 y 14 de la hemorragia subaracnoidea, a los cuales se realizo un estudio neurovascular contrastado y monitorizacion diaria con Doppler transcraneal. Todos los pacientes se encontraban con grado clinico de la escala de la Federacion Mundial de Cirujanos Neurologicos entre 1 y 3; 46 tenian aneurismas y en 20 el sangramiento fue intenso (grado 3-4 en la escala de Fisher). Resultados. La frecuencia de vasoespasmo angiografico fue del 41% en las arterias cerebrales anteriores. Las velocidades medias del flujo en los enfermos con vasoespasmo fueron de 84,5 cm/s. Los picos maximos de velocidad de flujo media se obtuvieron en el decimo dia. La sensibilidad fue del 57,9% para velocidades de flujo iguales o superiores a 87,5 cm/s, y el valor predictivo positivo fue del 66,6%. No se encontro relacion significativa entre el resultado del Doppler transcraneal, el grado clinico y la intensidad del sangramiento en la tomografia axial computarizada. Conclusion. La precision global de la prueba fue buena, la especificidad y el valor predictivo negativo fueron excelentes; sin embargo, la sensibilidad fue baja.

This prospective study assesses the role of intensive outpatient based conservative treatment in the management of aural polyp.All cases of aural polyp that presented to the department during 1990 were included. Patients with obvious cholesteatoma or in whom inner ear or intracranial pathology was suspected were excluded as were children and patients who had undergone previous ear surgery.We found that treatment with topical steroid/antibiotic decreases disease activity and renders subsequent surgery less extensive.

The evolution of low frequency variability in cerebral blood flow velocity (CBFV) was examined in 30 consecutive admissions of very low birthweight babies. Measurement of CBFV was made on the first day of life and at weekly intervals until discharge. Altogether 133 recordings were subjected to visual classification and described as showing presence or absence of variability at a frequency between 1 and 5/minute. Amplitude of variability was expressed as the largest variation in peak systolic velocity as a percentage of the maximum systolic change. Slow variability was usually obvious and was sometimes present for only part of the minute recorded. There was a significant trend for decreased incidence of slow variability in relation to both postconceptional and postnatal ages. Amplitude of slow variability was also damped with increasing age. Slow variability appeared to be unrelated to the type of sedation, severity of illness, or intracranial pathology; it may be a normal phenomenon in which damping occurs as the autonomic nervous system matures.

Forty-six cases of intracranial meningioma in patients above 70 years of age form the basis of this study; 34 underwent surgery while 12 did not. The decision to operate was based on the general condition of the patient, evaluated according to the Karnofsky index, neurological conditions, the site and dimensions of the tumor, and the presence of peritumoral edema. The post-surgical mortality rate was 11.5% at 30 days, and 20% at 3 months. Long-term follow-up in both patient groups ranged from 1 to 5 years, and quality of life was evaluated by the Karnofsky index. Five operated patients died during follow-up (only 1 from intracranial pathology); the 22 survivors showed further improvement in their grading level compared to scores immediately following surgery. Among the unoperated patients, 6 died within two years of diagnosis, all from causes related to intracranial pathology; among the survivors, the Karnofsky index was unchanged in 2, and diminished in the other 4 cases. (Aging Clin. Exp. Res. 4: 29–33, 1992)

In the Endgames quiz on intracranial pathology the diagnosis of a right sided fairly extensive chronic subdural haematoma of the convexity was clear in the initial computed tomogram. …

Summary A 28-year-old woman developed symptoms of raised intracranial pressure associated with an obstructive hydrocephalus following a spinal anaesthetic administered for a Kiellands rotation forceps delivery. A diagnosis of an unverified pineal body tumour was made after computerised axial tomography scanning and the symptoms were effectively treated by the insertion of a ventriculo-peritoneal shunt. This unusual case demonstrates the importance of careful history taking and neurological examination where symptoms of postspinal headache persist.