Abstract Introduction: Coronary risk factors in patients with acromegaly after first-line transsphenoidal surgery (TSS) or first-line somatostatine analogue (SSA) treatment have rarely been examined. Aim of this study was an evaluation of cardiovascular risk factors and left ventricular hypertrophy (LVH) in 3 different patient groups with treatment naïve, active (ACT), first-line medically controlled (MED) and first-line surgically treated (SUR) acromegaly and a calculation of the Framingham Weibull Risk Score (FS). Design: Retrospective comparative matched case-control study. Patients & Methods: 40 acromegalic patients (cases aged 45–74 years, 23 men) were matched with respect to age and gender to 200 controls from the general population. 13 patients had treatment-naïve acromegaly (ACT), 12 patients were SSA treated (MED) and 15 patients were operated by TSS (SUR). Coronary risk factors were assessed after 12 months of treatment by interviews and direct laboratory measurements. Only patients normalized for IGF-I in MED and SUR group were included. FS and odds ratios (OR) from multiple conditional logistic regression (matched for age and gender, adjusted for BMI) were calculated. Results: Compared to matched controls ACT patients had higher HbA1c levels (6.9±1.4 vs. 5.5±0.7% (p<0.0001)) and an increased prevalence of left ventricular hypertrophy (LVH) (30.8 vs. 3.2% (p=0.007). MED and SUR groups were similar for gender, age, disease duration and IGF-I levels at diagnosis. Compared to matched controls, MED patients had a significantly increased diastolic blood pressure (89±9 vs. 79±11 mmHg (p=0.001), prevalence of LVH (41.7 vs. 1.7% (p<0.0001), prevalence of diabetes mellitus (33.3 vs. 10.0% (p=0.03)), higher HbA1c levels (6.8±1.3 vs. 5.5±0.7% (p=0.0005)) and a higher FS (21.2±9.7 vs. 12.4±7.7% (p=0.002), OR 1.11 [1.02–1.21] (p=0.01)) while in the SUR group only higher prevalences of LVH (40.0 vs. 4.1% (p<0.0001)) and HbA1c levels (6.4±1.2 vs. 5.5±0.8% (p=0.006)) were found compared to controls. Conclusion: When comparing treatment naive, medically treated and surgically cured patients with acromegaly to age- and gender-matched subjects from the general population, we have found an increased cardiovascular risk in patients at 12 months after first-line SSA treatment but not in patients after first-line surgery.

Ziele: Die Vorteile der Hochfeld-MRT-Bildgebung resultieren aus einem höheren BOLD-Kontrast und können eine single event fMRT Bildgebung ermöglichen, von der insbesondere unkooperative Patienten profitieren. Jedoch führt die erhöhte Sensitivität zu vermehrten Suszeptibilitätsartefakten. Unser Ziel war die Evaluation des fMRT bei 7 T, zur prächirurgischen Detektion motorisch vulnerabler Hirnareale bei Tumorpatienten. Methode: Sechs Patienten mit Hirntumoren in der Nähe der Zentralregion wurden bei 1,5 und bei 7 Tesla untersucht, während sie mit der kontralateralen Hand ein „finger tapping“ Parameter in einer Block-Design Anordnung durchführten. Eine EPI-Sequenz mit kurzer TE wurde für die Erfassung des gesamten Gehirns ausgewählt. Bei 7 Tesla wurden 2 Patienten mit einer CP Sende-/Empfangs-Kopfspule sowie 4 Patienten mit einer 8-Kanal-Kopfspule untersucht; dabei wurde die PAT-Sequenz für die Erfassung der supratentoriellen Hirnregionen optimiert. Ergebnis: Die Signaländerung war bei allen untersuchten Patienten bei 7 T signifikant höher als bei 1,5 T (Faktor 2–3). Sogar in der single event Analyse konnte eine adäquate Antwort-Kurve aller in das „finger-tapping“ involvierten Hirnregionen erfasst werden. Signifikant reduzierte Artefakte sowie eine bessere Koregistrierung wurden mit der 8-Kanal-Kopfspule im Vergleich zur CP-Spule unter Beibehaltung des Vorteils durch das höhere Signal erzielt. Schlussfolgerung: Unsere Ergebnisse zeigen, dass fMRI bei Tumorpatienten von der Hochfeldtechnik einerseits profitiert, andererseits können jedoch ausgeprägte Suszeptibilitätsartefakte problematisch sein. Durch Verwendung einer 8-Kanal-Kopfspule mit PAT Sequenzen lassen sich diese Artefakte signifikant reduzieren. Diese Technik könnte ein sinnvoller Ansatz zur präoperativen Detektion vulnerabler Hirnareale, sogar mittels single event Technik, sein und sollte in einem größeren Kollektiv evaluiert werden.

OBJECTIVE:We retrospectively analyzed a series of patients who deteriorated after resection of an intracranial meningioma due to extensive brain edema (EBE) with regard to etiology of the neurological worsening and outcome.METHODS:Out of a series of 376 consecutive patients who underwent resection of an intracranial meningioma, 13 (3.5%) experienced postoperative deterioration due to EBE which necessitated prolonged artificial ventilation, tracheal reintubation, or decompressive craniectomy. Clinical data, radiological findings, operative records and follow-up data of these patients were retrospectively reviewed.RESULTS:The study revealed two different patient groups: Patients in group A (n=7) demonstrated edema due to typical venous infarction (VI). A decompressive craniotomy was performed in all but one patient in this group; nonetheless, an acceptable neurological outcome (Glasgow Outcome Scale (GOS) 4) was achieved in only two cases. Patients in group B (n=6) deteriorated due to an EBE of unknown etiology. Mean tumor volume in this group was higher when compared to group A (75 ml vs. 30 ml). In addition, 83% of patients in group B displayed extensive preoperative peritumoral edema compared to only 14% in group A. Three patients in group B required decompressive surgery; however, neurological outcome was more favorable in this group as 83% achieved a GOS of 4 or 5.CONCLUSION:Extensive brain swelling during or after intracranial meningioma surgery may be due to VI or possibly due to increased postoperative tissue permeability. It is recommended to preserve all venous structures as patients with VI had an unfavorable neurological outcome.

BACKGROUND AND PURPOSE: A controversial discussion concerning treatment of aneurysms in elderly patients exists. The aim of this study was to analyze clinical outcome in patients older than 65 years harboring intracranial aneurysms after endovascular treatment. MATERIALS AND METHODS: A total of 108 patients aged 65 years or older (mean age, 72 years, range, 65–87 years) were selected for endovascular treatment between 1997 and 2005. A total of 85 (78.7%) patients had an acute subarachnoid hemorrhage (SAH). SAH was classified according to Hunt and Hess (HH) grade: I (n = 16), II (n = 11), III (n = 33), IV (n = 19), and V (n = 6). There were 69 aneurysms that were small; 46, medium; 8, large; and 5, giant. Occlusion rate was categorized as complete (100%), subtotal (95% to 99%), and incomplete (<95%) obliteration according to the Raymond scale. RESULTS: Endovascular treatment was technically feasible in 108 of 113 aneurysms. Complete occlusion could be achieved in 80 patients; basal remnant was seen in 26 patients and a dog ear in 2 patients. Procedural complications included thrombotic vessel occlusion (n = 9), aneurysmal rupture (n = 4), and stenosis of the parent vessel (n = 2). The Glasgow Outcome Scale (GOS) for the patients with SAH after 6 months was good recovery (n = 43), moderate disability (n = 12), severe disability (n = 28), persistent vegetative state (n = 5), and death (n = 18). Outcome for the patients with unruptured aneurysms was good recovery in all 23 patients. On follow-up digital subtraction angiography (DSA) in 69 patients, complete aneurysmal occlusion was confirmed in 81% after 6 months. Five patients with recanalization were re-treated with coiling. CONCLUSION: Endovascular treatment of ruptured and unruptured intracranial aneurysms in this subgroup was safe and effective.

Zielsetzung: Die Vorteile der Hochfeld-MRT-Bildgebung resultieren aus einem höheren BOLD-Kontrast und einem höheren Signal-zu-Rausch-Verhältnis und können eine single event fMRT Bildgebung ermöglichen. Hiervon könnten insbesondere unkooperative Patienten profitieren. Jedoch führt die erhöhte Sensitivität zu vermehrten Suszeptibilitätsartefakten. Ziel war es, fMRT bei 7 T zu evaluieren und eine mögliche Anwendung zur prächirurgischen Detektion motorisch vulnerabler Hirnareale bei Tumorpatienten darzustellen.

Ziele: Ziel der Studie ist die vergleichende Visualisierung von Astrozytomen Grad II bis IV (WHO) und die Bestimmung ihrer Infiltrationstiefe in angrenzendes Hirnparenchym in der MRT mit 1,5-T (Tesla) bzw. 7,0-T. Das 4,7-fach höhere Signal bei 7,0-T gewährleistet eine 1,7-fach geringere Voxelgröße in allen drei Raumrichtungen gegenüber 1,5-T und somit eine detaillierte Darstellung der Tumorränder und Binnenstruktur von Hirntumoren. Methode: 15 konsekutive Patienten mit im 1,5-T MRT diagnostizierten, intrakraniellen Astrozytomen, wurden anschließend mit einem 7,0-T MRT (Siemens) untersucht. Die Lokalisation und Infiltrationstiefe der Astrozytome wurde von zwei Neuroradiologen ohne Kenntnis von Voraufnahmen und klinischen Angaben beurteilt. Die Bildqualität wurde anhand einer 5-Punkte-Skala evaluiert. Ergebnis: Bei einigen Patienten ist bei 7 Tesla die Heterogenität der Tumormatrix deutlich besser zu erkennen. Die Infiltrationstiefe ist mit 7 Tesla grundsätzlich besser sichtbar. Schlussfolgerung: Die Visualisierung von Astrozytomen bei 7,0-T erlaubt eine mehr als adäquate, diagnostische Darstellung von tumorinfiltriertem und gesundem Hirngewebe im Vergleich zu 1,5-T.

Ziele: Das 4,7-fach höhere Signal der 7,0-T (Tesla) MRT soll gegenüber der 1,5-T MRT aufgrund der 1,7-fach geringeren Voxelgröße eine detaillierte Darstellung und Charakterisierung intrakranieller Aneurysmen gewährleisten. Wir wollen untersuchen, ob die 7,0-T TOF MR-Angiographie im Vergleich zur 1,5-T TOF MR-Angiographie und der DSA – als Goldstandard – eine überlegene Methode zur Identifizierung und Visualisierung von intrakraniellen Aneurysmen ist. Methode: 10 konsekutive Patienten mit in der DSA nachgewiesenen, unversorgten Hirnarterienaneurysmen wurden einer 1,5-T TOF MRA und einer 7,0-T TOF MRA unterzogen. Das Vorhandensein und die Lokalisation der Aneurysmen wurde von zwei Neuroradiologen ohne Kenntnis der klinischen Daten und Voraufnahmen dokumentiert. Ferner wurden die Angiographien bezüglich der Bildqualität anhand einer 5-Punkte-Skala evaluiert. Ergebnis: Alle in der DSA dokumenierten Aneurysmen wurden auch in der 1,5-T und 7,0-T TOF MRA nachgewiesen. Die 7,0-T MR-Angiogramme erreichten eine annähernd vergleichbare Bildqualität zur DSA und eine signifikant höhere, mediane Bildqualität als die korrespondierenden 1,5-T MR-Angiogramme bei überlegener Darstellung von kleinen Aneurysmen und der Gefäßperipherie. Schlussfolgerung: Die 3 D TOF MR-Angiographie bei 7,0 T zeigt annähernd vergleichbare Ergebnisse zur DSA und eine verbesserte Bildqualität gegenüber der 1.5-T TOF MRA in Bezug auf die Identifizierung und Charakterisierung von intrakraniellen Hirnarterienaneurysmen.

Gunshot injuries to the head and brain are rare in Germany and the rest of western Europe. With the relatively low number of these injuries here, there are no standard methods of diagnosis and management, and there is some controversy over both. Quite a high proportion of such injuries result from suicide attempts and accidents. The main diagnostic procedure available is computed tomography of the head with contrast medium; in certain cases MRI is indicated. The operative management depends on the extent and prognosis of the injury; a ventricular drain is probably indicated in most cases. Debridement of the bullet's path and removal of the projectile are more controversial. Mortality is extremely high after such injuries; if the victim does survive the prognosis is comparable to that following closed cranial injuries.

Summary Background . A systematic investigation of long-term follow-up results after microsurgical treatment of patients harbouring an olfactory groove meningioma, particularly with regard to postoperative olfactory and mental function, has rarely been performed. We reassessed a series of patients treated microsurgically for an olfactory groove meningioma in regard to clinical presentation, surgical approaches and long-term functional outcome. Method . Clinical, radiological and surgical data in a consecutive series of 56 patients suffering from olfactory groove meningioma were retrospectively reviewed. Findings . Presenting symptoms of the 41 women and 15 men (mean age 51 years) were mental changes in 39.3%, visual impairment in 16.1% and anosmia in 14.3% of the patients. Preoperative neurological examination revealed deficits in olfaction in 71.7%, mental disturbances in 55.4% and reduced vision in 21.4% of the cases. The tumour was resected via a bifrontal craniotomy in 36, a pterional route in 13, a unilateral frontal approach in 4 and via a supraorbital approach in 3 patients. Extent of tumour resection according to Simpson’s classification system was grade I in 42.9% and grade II in 57.1% of the cases. After a mean follow-up period of 5.6 years (range 1–13 years) by clinical examination and magnetic resonance imaging (MRI), 86.8% of the patients resumed normal life activity. Olfaction was preserved in 24.4% of patients in whom pre- and postoperative data were available. Mental and visual disturbances improved in 88 and 83.3% of cases, respectively. Five recurrences (8.9%) were observed and had to be reoperated. Conclusions . Frontal approaches allowed better resection of tumours with gross infiltration of the anterior cranial base, tumours extending into the ethmoids or nasal cavity and in cases with deep olfactory grooves. Preservation of olfaction should be attempted in patients with normal or reduced smelling preoperatively.

OBJECTIVE:The purpose of this study was to analyse a series of patients harbouring an intracranial hemangiopericytoma (HPC) with respect to clinical presentation, treatment results and long-term follow-up outcomes.PATIENTS AND METHODS:Clinical data were retrospectively obtained in a series of 12 patients who underwent microsurgical resection for HPC at two neurosurgical institutions between 1987 and 2004.RESULTS:The main presenting symptoms in the seven men and five women (mean age 38 years) were headache in 50% and epileptic seizures in 33% of the patients. A Simpson grade I resection was achieved in seven patients (58%) and none of these patients developed local tumour recurrence after a mean follow-up period of 127 months (10.6 yrs). Only one of these patients received adjuvant radiotherapy. A recurrence of the HPC was observed in all patients (42%) who underwent subtotal tumour resection at first surgery (Simpson grade II or higher). Recurrences occurred after a mean period of 39 months (3.2 yrs) after primary surgery and were effectively controlled by surgical excision, radiotherapy and gamma knife radiosurgery. Two patients (17%) developed extraneural metastases which were treated by surgical excision, radiotherapy and salvage chemotherapy. Poly-chemotherapy was ineffective with respect to tumour control in this study.CONCLUSIONS:The study emphasises the importance of total resection of HPC, defined as a Simpson grade I removal, at first surgery. Adjuvant radiotherapy is recommended after subtotal tumour resections. A life-long vigilant follow-up of these patients is mandatory.

RATIONALE:Meningiomas in the pediatric age group are very rare tumors, comprising about 1-4.2% of all primary pediatric intracranial tumors.CASE REPORT:We present a 17-year-old patient who suffered from an intraventricular malignant meningioma. At the age of 2 years, acute lymphatic leukemia (common ALL [cALL]) was diagnosed and successfully treated with chemotherapy. There was no cranial radiation therapy. In December 2001, 13 years after diagnosis of cALL, he complained of headache, vomiting, and walking difficulties. Magnetic resonance imaging showed an enhancing mass with cystic components in the trigone of the right lateral ventricle. The tumor was removed completely. Histological diagnosis revealed a malignant papillary meningioma. After removal of a recurrent meningioma 16 months later, he received local radiotherapy.CONCLUSION:Pathogenetic mechanisms, treatment options, and prognosis of meningiomas and secondary malignancies of this age group are discussed.

The study demonstrates the feasibility of intraoperative fMRI to visualize the sensorimotor cortex employing 1.5 and 0.3 Tesla MRI scanners as well as a passive fMRI paradigm, which allows fMRI data acquisition in anesthetized patients.

Objectives: For somatostatin, five receptor subtypes (sst1–5) have been identified that are widely distributed in various endocrine tissues and tumors. Potent somatostatin analogs like octreotide, lanreotide and the new multiligand SOM230– with different binding properties to the receptor subtypes – have been developed.

Although hypopituitarism is a known complication of traumatic head injury, it may be under-recognized due to its subtle clinical manifestations. To address this issue, we determine the prevalence of neuroendocrine abnormalities in patients rehabilitating from severe traumatic brain injury (Glasgow Coma Scale < or = 8). 76 patients (mean age 39 +/- 14 yr; range 18-65; 53 males and 23 females; BMI 25.8 +/- 4.2 kg/m2; mean +/- SD) with a severe traumatic brain injury, an average of 22 +/- 10 months before this study (median, 20 months), underwent a series of standard endocrine tests, including TSH, free T4, T4, T3, prolactin, testosterone (males), estradiol (females), cortisol, ACTH, GH, and IGF-I. All subjects also underwent GH response to GHRH + arginine. Growth hormone deficiency (GHD) was defined as a GH response < 9 microg/L to GHRH + arginine and was confirmed by ITT (< 3 microg/L). Pituitary deficiency was shown in 24% of the patients (18/76). 8% (n = 6) had GHD (GH-peak range [GHRH + arginine]: 2.8-6.3 microg/L; GH-peak range [ITT]: 1.5-2.2 microg/L; IGF-I range: 62-174 microg/L). 17% (n = 13) had hypogonadism (total testosterone < 9.5 nmol/L and low gonadotropins in 12 males; low estradiol, and low gonadotropins in 1 female). Total testosterone levels did not correlate with BMI or age. 2 males with hypogonadism also showed a mild hyperprolactinemia (33 and 41 ng/ml). 3% (n = 2) patients had partial ACTH-deficiency (cortisol-peak [ITT] 392 and 417 nmol/L) and 3% (n = 2) had TSH-deficiency. In summary, we have found hypopituitarism in one-fourth of patients with predominantly secondary hypogonadism and GHD. These findings strongly suggest that patients who suffer head trauma must routinely include neuroendocrine evaluations.

BACKGROUND AND PURPOSE:Middle cerebral artery (MCA) aneurysms often have an unfavorable aneurysm geometry that might limit endovascular therapy. Our purpose was to analyze the feasibility, safety, and efficacy of coil embolization in a consecutive series of MCA aneurysms chosen for endovascular treatment.PATIENTS AND TECHNIQUES:Of 235 MCA aneurysms seen at our institution during the past 5 years, 36 patients harboring 38 MCA aneurysms were primarily selected for coil embolization: 18 patients had an acute subarachnoid hemorrhage (SAH), 16 of which were due to a ruptured MCA aneurysm. SAH was classified according to Hunt and Hess grade: I (5), II (7), III (5), IV (0), and V (1).RESULTS:Complete occlusion could be achieved in 33 of 38 aneurysms. In 5 aneurysms, coil embolization was not performed because of an unfavorable aneurysm geometry with a wide neck or incorporation of adjacent branches (3) or failed because of insecure coil placement (1) or severe vasospasm (1). Procedural complications included coil protrusion into the parent artery (1), and thromboembolic M2 occlusion (5), with recanalization in 4 of 5 cases. Of 8 aneurysms with initial subtotal occlusion, 3 progressed to total occlusion during follow-up. Three aneurysms had to be retreated, and no patient rebled. Glasgow Outcome Scale at 6 months for the patients with SAH (17/18) was good recovery (12), moderate disability (4), severe disability (0), persistent vegetative state (0), and death (1); outcomes for patients with an incidental aneurysm (17/18) were good recovery (16) and moderate disability (1).CONCLUSION:Endovascular coil embolization can be performed safely and effectively in selected MCA aneurysms. Initial subtotal aneurysm occlusion might progress to total occlusion.