Traumatic aneurysms of the meningeal arteries are usually associated with blunt trauma [9] [13] [17]. They often manifest as false aneurysms or pseudoaneurysms resulting from incomplete disruption of the vessel wall [3]. While pseudoaneurysms of the middle meningeal artery have been reported occasionally [2] [3] [6] [10] [16] [25] [27], pseudoaneurysms of the posterior meningeal artery are exceedingly rare [8] [22] [26]. Hemorrhage secondary to rupture of a traumatic meningeal artery aneurysm is a serious event associated with high morbidity [1] [2] [3] [5] [6] [7]. There is very limited data on appropriate treatment strategies. Here we present the first case, in which a traumatic pseudoaneurysm was treated using a bioactive coil.
Introduction & Intraosseous venous blood drains into the central basiventral vein which connects to the venous plexus in the anterior epidural space. Two pathways have been described for the drainage of this venous plexus. The fi rst pathway is along the internal vertebral veins which run caudally and cranially in the anterior spinal canal and are interlinked. The second pathway is along the valve-less radicular veins which run laterally to the extraspinal compartment and connect directly to the inferior vena cava. An increase of pressure in the inferior vena cava may thus occasionally be transferred into the intraspinal compartment [17] . We report the fi rst case of symptomatic epidural varix formation due to alcohol-associated liver cirrhosis with portocaval hypertension and performed a review of the literature especially addressing the therapeutic options.
Introduction & Melanotic schwannoma (MS) is a very rare nerve sheath tumor characterized by melanin-producing cells that display ultrastructural features of Schwann cells [24] . This type of tumor was fi rst described in 1932 [17] and occurs primarily in the paraspinal region, originating from the spinal nerve roots or sympathetic ganglia. Craniofacial or intracranial locations are rare [15, 21] . However, extraneural locations such as skin, soft tissues, bone and viscera have also been described [5, 7] . In a minority of cases, MS may have multiple nodules [6, 26] . Although MS have been considered to be slow-growing, benign tumors, prognosis can be poor as a result of local recurrence or malignant progression [9] . Melanotic schwannoma occurs in relatively young adults (mean age 35 years) and have no sex predilection. Epidemically, two types of tumors can be distinguished: the sporadic variant and psammomatous melanotic schwannoma associated with the Carney complex, a rare, autosomal dominant hereditary syndrome characterized by variegated skin pigmentation, cardiac myxomas, endocrine overactivity, and nerve sheath tumors [2] . Psammoma bodies are present in more than 50 % of MS. Immunohistochemistry reveals that S100, HMB-45 and vimentin are strongly expressed by most cells in MS [15, 18] .
Perivascular spaces (PVSs) of the brain, also known as Virchow-Robin spaces, are pia-lined cavities surrounding brain arteries and arterioles as they penetrate into the cerebral tissue [13] [16]. Cystic cavities have first been described in the literature in 1838, as small cavities in the globus pallidus and putamen [2].
Neurosurgery and medicine in general are increasingly dominated by economic factors and considerations. Physicians themselves have partially adopted economic terminology, although they rarely have a profound knowledge of economics. Today game theory is one of the most important factors driving microeconomics, which is the competition for limited resources within a small group of individuals. The purpose of this article is to give a short introduction to game theory and its application to the healthcare system. The Prisoner's Dilemma considers strategies between two persons. In the classic version two burglars are caught. Each could confess and be released from jail if the other does not confess--who will then get a long term in prison. If both confess, both get an intermediate time in jail, and if no one confesses, both get a mild sentence. Wanting to be released from jail, they both confess and get the intermediate term in prison. This remarkable result, initially described by John von Neumann in 1928 and showing that individually rational actions can result in both persons becoming worse off, had a great impact on modern social science. Other scenarios are more complex. The Nash Equilibrium is a wider concept. If there is a set of strategies with the property that no player can benefit by changing his strategy while the other players keep their strategies unchanged, then that set of strategies and the corresponding payoffs constitute the Nash Equilibrium. Another concept particularly important in sociology is the Pareto criterion. If no one can be made better off without making somebody else worse off, then that outcome is Pareto optimal. Respecting these basic principles is a necessary precondition for successful deals and cooperative projects.
Background: Critical incident monitoring is an important tool for quality improvement and the maintenance of high safety standards. It was developed for aviation safety and is now widely accepted as a useful tool to reduce medical care-related morbidity and mortality. Despite this widespread acceptance, the literature has no reports on any neurosurgical applications of critical incident monitoring. We describe the introduction of a mono-institutional critical incident reporting system in a neurosurgical department. Furthermore, we have developed a formula to assess possible counterstrategies.Methods: All staff members of a neurosurgical department were advised to report critical incidents. The anonymous reporting form contained a box for the description of the incident, several multiple-choice questions on specific risk factors, place and reason for occurrence of the incident, severity of the consequences and suggested counterstrategies. The incident data was entered into an online documentation system (ADKA DokuPik) and evaluated by an external specialist. For data analysis we applied a modified assessment scheme initially designed for flight safety.Results: Data collection was started in September 2008. The average number of reported incidents was 18 per month (currently 216 in total). Most incidents occurred on the neurosurgical ward (64 %). Human error was involved in 86 % of the reported incidents. The largest group of incidents consisted of medication-related problems. Accordingly, counterstrategies were developed, resulting in a decrease in the relative number of reported medication-related incidents from 42 % (March 09) to 30 % (September 09).Conclusions: Implementation of the critical incident reporting system presented no technical problems. The reporting rate was high compared to that reported in the current literature. The formulation, evaluation and introduction of specific counterstrategies to guard against selected groups of incidents may improve patient safety in neurosurgical departments.
Objective: Enquiries among surgical trainees revealed an increasing discontent regarding their quality of training. 40% of young surgical trainees judge their training as inadequate and 70% are offered no structured training programme. Working time restrictions and economic pressure may be strong factors hindering residents from becoming skillful surgeons. Therefore, additional forms of training seem to be needed.Method: An in vivo swine model was evaluated for its practical use in training neurosurgical residents. Surgical procedures included craniotomy, dural opening, brain surgery and excision of an artificial tumour created by injection of coloured fibrin glue. Microscopy and bleeding management with bipolar cautery and haemostyptics were an integrated part of training. Supervision by experienced neurosurgeons with up to 3 trainees in a 2-day course was warranted. Standardised questionnairies before and after training were used to assess the quality and utility of the programme.Results: 24 residents have participated in the course (1(st)-5(th) year of training). Minor experience with less than 100 conducting surgeries was seen in 59% of trainees. 14 residents had participated in more than 100 surgeries as first assistant. Spinal surgery was the predominant common experience. All participants judged their surgical training as insufficient. 77% had no microsurgical lab at their clinics. Expectations for the course were met for all trainees and the tutorials judged as excellent (65%) or good (35%). Positive evaluations of the in vivo model (97%), a realistic laboratory setup (94%), the working environment (94%) and close supervision (94%) showed that these were the most favourable aspects of the course.Conclusion: Educational training in surgical specialities is becoming a major problem in our daily practice and requires additional training facilities. In this context, in vivo models are an ideal opportunity for young neurosurgeons to train bleeding management and surgical complications in particular. This educational form is thought to be a unique training model which is now added by spinal and neurovascular courses.
The presence of air in the spinal canal is referred to as pneumorrhachis (PR). The proposed causes of PR are iatrogenic, non-traumatic, and traumatic [7] [14]. Air in the spinal canal may be extradural (epidural) or intradural (subdural and subarachnoid) and is found in an isolated form at the cervical, thoracic, and lumbosacral levels or as a diffuse form in the entire spinal canal [14]. Traumatic PR can be also classified as intradural (subdural or subarachnoid) or extradural (epidural) and is associated with different pathophysiologic mechanisms and causes [7] [14]. In general, the occurrence of air within the epidural space is more common than intradural PR. The presence of epidural air has a different implication from subarachnoid PR. Epidural PR is usually benign, innocent, asymptomatic, resolves spontaneously and is usually localized to a fracture line [7] [14]. The underlying cause should be treated. Traumatic subarachnoid PR is secondary to major trauma, and usually accepted as an indirect sign of severe injury. Traumatic subarachnoid PR, which is almost always associated with pneumocephalus, needs more detailed investigation, close monitoring, and follow-up because air in the subarachnoid space may lead to increased or decreased intracranial and intraspinal pressure as it moves up or down, resulting in neurological signs and symptoms [22] and even mortality [3] [16]. The management of subarachnoid air is not just limited to the underlying cause. Potential complications such as persistent pneumocephalus and infection associated with subarachnoid PR should be prevented and, if necessary, the torn dura should be repaired.
Foramen magnum meningioma (FMM) is a very rare intracranial lesion[1]. It constitutes such a small percentage (about 2%) of brain tumors[2] that even high volume neurosurgical centers in Western countries report series averaging only one case per year[2] [3]. One explanation for this rarity is the difficulty in making a clinical diagnosis of FMM, especially before the advent of diagnostic magnetic resonance imaging (MRI)[4] [5] [6]. The other, more important, reason, however, is the great technical challenge of tumor-ablative surgery in the foramen magnum, a highly limited bony region crowded over by many critical neural-vascular structures of the cervicomedullary junction[7] [8] [9]. This may actually be the main reason why reports of surgical treatment of FMM are much rarer still from resource-poor settings. We present one case recently managed successfully in such a practice setting in Nigeria. We are not aware of any other similar report in the accessible literature from Africa.
Tako-tsubo cardiomyopathy or "apical ballooning" was first described in Japan in 1990 by Satoh et al. [7] The syndrome is characterized by transient left ventricular dysfunction resulting from severe physical or emotional stress. This report describes a 64-year-old woman who underwent CPR (cardiopulmonary resuscitation) because of severe cardiac failure due to tako-tsubo cardiomyopathy. A subarachnoid hemorrhage (SAH) from a ruptured anterior communicating aneurysm was diagnosed as the underlying cause seven days later.
Background and Purpose: In conventional MR imaging, it is often difficult to delineate the heterogeneous structure of gliomas. Proton magnetic resonance spectroscopic imaging ((1)H-MRSI) is a noninvasive tool for investigating the spatial distribution of metabolic changes in brain lesions. The aim of this study was to assess the improvements in delineation of gliomas based on segmentation of metabolic changes measured with (1)H-MRSI.Material and Methods: Twenty patients with gliomas (WHO grade II and III) were examined using a standard (1)H-MRSI sequence. Metabolic maps for choline (Cho), N-acetyl-aspartate (NAA) and Cho/NAA ratios were calculated and segmented based on the assumption of a Gaussian distribution of the Cho/NAA values for normal brain. Areas of hyperintensity on T2-weighted (T2w) MR images were compared with the areas of the segmented tumor on Cho/NAA maps. Stereotactic biopsies were obtained from the MRSI/T2w difference areas.Results: In all patients, the segmented MRSI tumor areas were greater than the T2w hyperintense areas, on average, by 20% (range 6-34%). In nine patients, biopsy sampling from the MRSI/T2w difference areas showed tumor infiltration ranging from 4-17% (mean 9%) tumor cells, in the areas detected only by MRSI.Discussion and Conclusion: Our method for automated segmentation of the lesion-related metabolic changes achieved significantly improved delineation for gliomas compared to routine clinical methods. We demonstrate that this method can improve delineation of tumor borders compared to routine imaging strategies in clinics. Metabolic images of the segmented tumor may thus be helpful for therapeutic planning.
Trephinations in Neolithic people have been described all over the world. The reasons for these operations however are not always clear. In the present paper the authors describe the rare case of a Neolithic skull (dated to 1940 cal BC [calibrated before Christ]) showing the combination of a trephination combined with a healed depressed skull fracture. The authors conclude that at least in some cases such operations have been performed for "purely" medical reasons.
Introduction: Nasofrontal dermoid fistulas that extend intracranially through the foramen cecum are extremely rare and can be difficult to completely resect.
Objective: Despite modern microsurgical techniques and interdisciplinary treatment options, intramedullary spinal cord tumors often lead to profound neurological deficits. Some patients may search for non-scientific or unconventional therapeutic options to treat the symptoms induced by the tumor itself or arising from treatment. The extent of non-scientific therapy use, the rationale behind it, and costs of these forms of therapy are unknown.Methods: A questionnaire consisting of 20 questions was sent to 60 patients of a single neurosurgical center who had undergone surgery for an intramedullary spinal cord tumor. A retrospective study was carried out based on this data. Histological findings ranged from ependymoma (52.9%), hemangioblastoma (17.6%), cavernoma (14.7%), astrocytoma (8.8%), oligodendroglioma (2.9%) to ganglioglioma (2.9%). Non-scientific therapy was defined as a method not used in routine clinical practice for the treatment of symptoms induced by intramedullary spinal cord tumors.Results: A total of 38 questionnaires was returned. About 55.3% of the patients claimed to use non-scientific therapies. No significant difference between histological types and the percentage of alternative therapy use was detected. There was a gender difference. One third (non user group) to one fourth (user group) did not feel adequately informed about their disease. The monthly costs for non-scientific therapies ranged from 50 to 500 Euros. The main motive for the use of non-scientific therapies was the wish to try everything possible.Conclusion: In the daily clinical routine, patients' use of non-scientific therapies may be largely overlooked and underestimated. Neurooncologists should be aware of this phenomenon and encourage an open but critical dialogue with their patients.
AIM:Gunshot wounds to the head are rare in Europe. They may be inflicted by low-velocity handguns, captive bolt guns and tear gas cartridges and mostly result from suicide attempts. The experience of neurosurgeons with this kind of traumatic injury is decreasing; the aim of this study was therefore to analyse prognostic factors which help to decide whether or not to operate and to discuss treatment options.METHODS:Thirty patients with gunshot head injuries treated in our hospital from 1993 to 2008 were retrospectively evaluated. Glasgow Coma Scale (GCS) score, pupil reactivity, lesion localisation, number of bone fragments, intracranial pressure (ICP), midline shift, hypotension, and dural penetration were analysed for their prognostic value. Surgically and non-surgically treated patients were evaluated separately. Complications were registered.RESULTS:A low GCS of 3-8, fixed pupils, >2 bone fragments, bilobar or posterior fossa/brainstem lesions and ICP >45 mmHg were indicators of a poor prognosis.CONCLUSION:Patients with a GCS of 3-8 and two non-reactive pupils should not be operated. If one or both of the pupils are reactive, surgery should be performed irrespective of the GCS score, except in patients with translobar/transventricular wounds. Even if there are no clear contraindications to surgery, the outcome is expected to be poor in patients with a low GCS score, midline shift >10 mm, >2 bone fragments in the brain, and a bilobar, posterior fossa/brainstem or ventricular lesion and ICP >45 mmHg. When surgery is performed the wound and the missile or bone track should be debrided meticulously, the wound and dura should be closed in a watertight fashion and antibiotic prophylaxis as well as tetanus serum should be given.
Much of the uncertainty regarding the true incidence and prognostic value of secondary ischemia from tSAH and VSP stems from the lack of diagnostic accuracy using transcranial Doppler sonography (TCD) fl ow velocities in the basal cerebral circulation or cumbersome imaging techniques (e. g. cerebral angiography, nuclear Abbreviations ▼ ACA anterior cerebral artery aSAH aneurysmal subarachnoid hemorrhage CBV cerebral blood volume CT computer tomography CTA computed tomography angiography DIND delayed ischemic neurological defi cit DWI diff usion-weighted imaging FLAIR fl uid attenuation inversion recovery HHH hypertension, hypervolemia, hemodilution ICA internal carotid artery MCA middle cerebral artery MR magnetic resonance MRA magnetic resonance angiography MRI magnetic resonance imaging PWI perfusion-weighted imaging SAH subarachnoid hemorrhage TBI traumatic brain injury TCD transcranial Doppler sonography tSAH traumatic subarachnoid hemorrhage TTP time-to-peak VSP cerebral vasospasm
Chondromyxoid fibromas are rare benign tumors of the bone and constitute only 0.5% of all primary bone tumors[13]. They originate from cartilaginous tissue and usually occur in young adults. Chondromyxoid fibromas frequently arise from the metaphysis of the long bones [18]. Chondromyxoid fibroma of the skull is extremely rare ([Table 1]). Residual embryonic cartilage tissue may be the origin of skull chondromyxoid fibromas. Here we describe a case of chondromyxoid fibroma located in the cerebellopontine angle.
Purpose: Methods: Results: Conclusion:
The PHACES syndrome is a neurocutaneous disorder whose acronym describes a constellation of congenital abnormalities including posterior fossa malformations, hemangiomas of the face and scalp, arterial malformations, coarctation of the aorta with other cerebrovascular and cardiac defects, eye anomalies, as well as sternal clefting or superumbilical raphe. Numerous posterior fossa anomalies associated with PHACES, such as Dandy-Walker malformation, have been previously described in the literature[1]. Recently, a case of cerebellar pilocytic astrocytoma in association with PHACES was described, introducing the possibility that neoplasms may occur in addition to the other posterior fossa malformations[2]. Here, we present the case of a 16-year-old adolescent boy with PHACES syndrome who was found to have a brainstem glioma. The patient had been treated at our neurosurgical center three years earlier for a giant fusiform internal carotid artery (ICA) aneurysm ipsilateral to the side of his facial hemangioma and was the subject of a previous case report[3]. Review of the literature revealed only two previous cases of gliomas[2] [4] in association with this condition. We believe this is the first case of brainstem glioma associated with PHACES syndrome and that it provides further evidence for an association between neoplasms and PHACES syndrome.
Object: Patients and methods: Results: Conclusions:
