To describe the results of conformal radiotherapy in advanced juvenile nasopharyngeal angiofibroma in a tertiary care institution.Retrospective chart review was conducted for 8 patients treated with conformal radiotherapy between 2006 and 2009. The median follow-up was 17 months. All patients had Stage IIIB disease with intracranial extension. Radiotherapy was considered as treatment because patients were deemed inoperable owing to extensive intracranial/intraorbital extension or proximity to optic nerve. All but 1 patient were treated with intensity-modulated radiotherapy using seven coplanar fields. Median (range) dose prescribed was 39.6 (30–46) Gy. Actuarial analysis of local control and descriptive analysis of toxicity profile was conducted.Despite the large and complex target volume (median planning target volume, 292 cm3), intensity-modulated radiotherapy achieved conformal dose distributions (median van't Reit index, 0.66). Significant sparing of the surrounding organs at risk was obtained. No significant Grade 3/4 toxicities were experienced during or after treatment. Actual local control at 2 years was 87.5%. One patient died 1 month after radiotherapy secondary to massive epistaxis. The remaining 7 patients had progressive resolution of disease and were symptom-free at last follow-up. Persistent rhinitis was the only significant toxicity, seen in 1 patient.Conformal radiotherapy results in good local control with minimal acute and late side effects in juvenile nasopharyngeal angiofibromas, even in the presence of advanced disease.

In a clinical study we examed patients with intracranial aneurysms. We compared CT-angiography (CTA) with MR-angiography (MRA) and Digital Substruction angiography (DSA) and evaluated the ability of the compared techniques to identify the neck of aneurysms and to visualize small arterial branches. The sensitivity of CTA and DSA to detect small intracranial aneurysms is higher compared with MRA. In giant aneurysms CTA using Volume Rendering Techcnique (VRT) can be superior to DSA and MRA. CTA using VRT offers very interesting new aspects in the diagnosis of intracranial aneurysms. CTA can help to better plan the therapeutic procedure in patients with giant aneurysms.

The purpose of the present study was to characterize the acute (30-day) surgical risk profile of pediatric patients undergoing surgical resection of intramedullary spinal cord tumors (IMSCTs).Preoperative factors were collected from the Pediatric American College of Surgeons National Surgical Quality Improvement Program database for patients identified by Current Procedural Terminology codes for laminectomy and International Classification of Diseases codes for IMSCTs from 2012 to 2016. The postoperative outcomes were compared by tumor location and type.The mean age of the 139 patients meeting all inclusion criteria was 8.7 years, with a male predominance (58.7%). The cervical and thoracic IMSCT populations had worst preoperative health status, as indicated by American Society of Anesthesiologists class, and a greater proportion of malignant tumors compared with the lumbar IMSCT population. No patient died; 8.6% of the patients were readmitted, and 6.5% required reoperation. Of the 12 readmissions, 8 were required for patients with malignant tumors. The patients with cervical IMSCTs returned to the operating room at a significantly greater rate than did the thoracic and lumbar IMSCT populations. Two common reasons for reoperation in the cervical population were issues related to respiration and hydrocephalus management. The complications included 13 cases of infection, 6 of urinary tract infection, and 5 cases of surgical site infection.Resection of IMSCTs in the pediatric population is a relatively low-risk procedure in terms of acute surgical complications. However, surgeons operating in the cervical spine should be aware of the increased risk of reoperation, in particular as it pertains to respiratory issues and hydrocephalus.

BACKGROUND AND PURPOSE:Various biological signals show nonpulsatile, slow rhythmic oscillations. These include arterial blood pressure (aBP), blood flow velocity in cerebral arteries, intracranial pressure (ICP), cerebral microflow, and cerebral tissue PO2. Generation and interrelations between these rhythmic fluctuations remained unclear. The aim of this study was to analyze whether stable dynamic interrelations in the low-frequency range exist between these different variables, and if they do, to analyze their exact time delay.METHODS:In a clinical study, 16 comatose patients with either higher-grade subarachnoid hemorrhage or severe traumatic brain injury were examined. A multimodal digital data acquisition system was used to simultaneously monitor aBP, flow velocity in the middle cerebral artery (FVMCA), ICP, cerebral microflow, and oxygen saturation in the jugular bulb (SjO2). Cross-correlation as a means to analyze time delay and correlation between two periodic signals was applied to a time series of 30 minutes' duration divided into four segments of 2048 data points (approximately 436 seconds) each. This resulted in four cross-correlations for each 30-minute time series. If the four cross-correlations were consistent and reproducible, averaging of the original cross-correlations was performed, resulting in a representative time delay and correlation for the complete 30-minute interval.RESULTS:Reproducible cross-correlations and stable dynamic interrelations were found between aBP, FVMCA, ICP, and SjO2. The mean time delay between aBP and ICP was 6.89 +/- 1.90 seconds, with a negative correlation in 81%. A mean time delay of 1.50 +/- 1.29 seconds (median, 0.85 seconds) was found between FVMCA and ICP, with a positive correlation in 94%. The mean delay between ICP and SjO2 was 9.47 +/- 2.21 seconds, with a positive correlation in 77%. Mean values of aBP and ICP did not influence the time delay and dynamic interrelation between the different parameters.CONCLUSIONS:These results strongly support Rosner's theory that ICP B-waves are the autoregulatory response of spontaneous fluctuations of cerebral perfusion pressure. There is casuistic evidence that failure of autoregulation significantly modifies time delay and the correlation between aBP and ICP.

Die transkranielle Dopplersonographie (TCD) wird seit etwa 8 Jahren routinemäßig zur Verlaufskontrolle des Vasospasmus nach Subarachnoidalblutung (SAB) eingesetzt. Ein hoher Anteil an falsch-positiven bzw. falsch-negativen Ergebnissen sowie ein nicht exakt definierbarer pathologischer Bereich führten allerdings zu einer erheblichen Einschränkung der Aussagekraft, vor allem im Hinblick auf die Vorhersage möglicher Defizite [3, 4, 6].

DURING RECENT YEARS, the management of subarachnoid hemorrhage (SAH) has changed, resulting in an increase in early operations and routine administration of nimodipine. Both influenced the indication for transcranial Doppler sonography (TCD). Furthermore, investigations detected discrepancies between Doppler findings and neurological status. In a prospective study, the reliability of TCD was investigated in patients with SAH treated with intravenously administered nimodipine. Patients with large hematomas were excluded. Neurological deficits immediately after surgery or within the first 48 hours were classified as not delayed, and therefore not necessarily due to vasospasm. The most remarkable points of this study are that there is no significant difference between the flow velocities for Hunt and Hess Grades I and II when compared with those for Grade III, and that Grades IV and V seem to be affiliated with the lowest velocities. When the flow velocities of 11 patients who developed delayed ischemic deficits (DIDs) were compared with those of patients with no deficit, no significant difference was seen. A significant increase in velocity in the days before the onset of DID was found only in 3 of 11 cases. Eight patients showed either constant high or constant low velocities or even, in some cases, decreasing time courses. High flow velocities did not necessarily mean impending neurological deficits: 8 of 66 patients tolerated flow velocities over 200 cm/s. Therefore, it no longer seems to be justified to proclaim that TCD is able to predict neurological deficits, although it is doubtless able to detect vasospasm. In an additional series of 97 normal subjects, flow velocities were found to be higher than reported in the literature, but this fact seems to explain only a minor proportion of the discrepancies. The main difference between this series and older investigations is the routine administration of nimodipine. In patients admitted within 48 hours after SAH (commonly no vasospasm) or with poor grade SAHs (commonly low flow velocities) TCD seems to have no value. Even in patients admitted later than 72 hours, the indication for TCD depends on the local management. If surgery is to be performed even in cases of asymptomatic vasospasm, the clinical value of TCD in cases of SAH is questionable.

Gewandelt hat sich das Management traumatischer intracranieller Blutungen in allen Teilen der Versorgungskette. Neu ist dabei die Möglichkeit einer Standbildübertragung von CT-Aufnahmen. Im Zentrum steht jedoch das perioperative Management mit dem Ziel der Vermeidung von sekundären Hirnschäden. In diesem Bereich unterscheiden wir bewährte Standardverfahren von perspektivischen Therapiemodellen. In diesem Zusammenhang ist ein kontinuierliches Monitoring des intracraniellen Druckes sowie eine engmaschige Dokumentation, z. B. mit Hilfe der Glasgow-Coma-Scale entscheidend.

For more than 8 years, transcranial Doppler sonography (TCDS) has been an important noninvasive tool in detecting vasospasm after subarachnoid hemorrhage (SAH). While initial investigations found a good correlation between the evaluated flow velocities and the neurological status, recent reports were more reserved. Especially the predictive value of TCDS concerning imminent delayed ischemic deficits (DID) was doubted [12, 14, 15]. This fact was mainly due to extremely high flow velocities being tolerated without any neurological deficit.

The management of aneurysmal subarachnoid hemorrhage (SAH) is mainly based on timing and grading. Meanwhile these problems seem to be solved for Hunt and Hess grades I, II, and in. The early operation within 48 h after SAH is the most adequate therapy to prevent rebleeding before onset of vasospasm.

INTRODUCTION:Postoperative intensive care of the elderly neurosurgical patient differs considerably from that of the younger patient.INVESTIGATION:Analysis of 106 patients aged between 68 and 92 years.RESULTS:In addition to the cardiopulmonary risk factors, the age-specific changes in the brain have an effect on the spectrum of postoperative complications. Age-related atrophy of the brain and in increase in the fragility of blood vessels due to degenerative processes increase the risk of subdural and intracerebral hemorrhage. The amount of time spent in the intensive care unit as a percentage of overall hospitalization is, at 50%, appreciably greater than that of younger patients. Intensive monitoring, including intracranial pressure and transcranial Doppler ultrasonography are useful for detecting intracranial complications at an early stage.CONCLUSIONS:Despite the appreciably greater duration of postoperative intensive care in the elderly, the overall outcome is comparable with that seen in younger patients in many neurosurgical conditions.

Transcranial Doppler Sonography (TCDS) is a well-established method for detecting changes in flow velocities in basal cerebral arteries following subarachnoid hemorrhage. However, conclusions on cerebral blood flow cannot be directly drawn from such TCDS findings. In addition, recent investigations have shown further restrictions because of discrepancies between Doppler findings and patients’ neurological status [1–3].

The first transcranial Doppler sonography (TCDS) examinations were all performed in an era without the standard clinical use of the calcium antagonist nimodipine. All these examinations had shown a strong correlation between signs of radiological vasospasm, elevated flow velocity (FV) measured by TCDS, and clinical signs of delayed ischemic (= neurological) deficits (DIDs). Best prediction of impending DID was possible in the area of the middle cerebral artery (MCA), and limits of absolute FV for predicting the impending risk of DIDs were published. In addition, the importance of the daily increase in FV (delta FV) was stressed. Since recent publications [7] on the therapeutic influence of nimodipine on cerebral vasospasm show a statistical decrease in the clinical DID without any remarkable change in the radiological vasospasm, it was the aim of this study to verify the above-mentioned data in a group of patients treated routinely with nimodipine and to examine the clinical significance of different pulsatility indices (Pis). Different authors [6,9] have suspected a significant change to occur in cases of DID. In cases of proximally located vasospasm accessible to TCDS, increased Pis measured proximally to an area of increased FV (= vasospasm) would be expected. In cases of DID without any alteration of FV, where a peripheral vasospasm could be assumed to lie outside the TCDS range, examination of the Pis might be of great interest, because an elevation of the peripheral resistance might cause an elevation of the Pis. As a well-known example of PI sensitivity caused by an increase in resistance, pre- and postoperative hemodynamic changes in arteriovenous malformations (AVMs) are precisely documented [5].

In 19 patients with bilateral proliferative diabetic retinopathy we examined the blood velocity in the ophthalmic artery with pulsed ultrasound and analyzed the outline of the pulse curve with the fast fourier transformation. The data were compared with the results in 50 normal objects. Patients with diabetic proliferative retinopathy showed increased systolic blood velocities (p less than 0.05), decreased diastolic blood velocities (p less than 0.05) and an alteration in the outline of the pulse curve (p less than 0.001). These changes can be due to diabetic-induced decrease in the elasticity of the wall of the ophthalmic artery and to microangiopathic alterations in the choroid. In some patients in the course of the ophthalmic artery, we saw localized peaks in the blood velocity, which can be interpreted as local stenosis in the ophthalmic artery.

Some ocular diseases lead to temporary changes in the ocular blood circulation. This study was undertaken to evaluate changes in the blood-flow velocity of the ophthalmic artery in patients with endophthalmitis. With pulsed Doppler sonography the blood velocity of the ophthalmic artery was measured in 50 normal subjects and in ten patients with bacterial endophthalmitis. In normal subjects blood velocity decreased with increasing age, and the average systolic/diastolic blood velocity in cm/sec were 38.8 +/- 6.3/11.6 +/- 4.7 in the 18-50-year-old age group and 28.3 +/- 4.6/6.7 +/- 3.3 in the 51-88-year-old age group. Endophthalmitis produced increased systolic/diastolic blood velocity in the ophthalmic artery in the affected eyes in cm/sec (99.7 +/- 15.5/26.6 +/- 10.5 in the 16-50-year-old age group; 60.4 +/- 8.8/16.6 +/- 4.8 in the 51-83-year-old age group). Some patients showed similar changes in the unaffected fellow eyes. The noted elevation of the blood velocity in unaffected eyes may be due to the bilaterally projected parasympathetic fibers of the oculomotor nerve.

Blood-flow velocity in the ophthalmic artery was examined at different orbital depths by pulsed ultrasound (4 MHz). Blood-flow velocity was influenced by patient age and showed a decrease in the vicinity of the eye. Forty-one normal subjects had an average systolic and diastolic blood-flow velocity of 36.5 and 10.9 cm/s at a 36 mm depth.