Frank Marguth

Neurosurgical management of cerebellar hemorrhage

Controversy remains concerning the management of patients with cerebellar hemorrhage. In this study the records of 42 patients were reviewed. In 60% of them the signs of brainstem compression and upward transtentorial herniation were found. The level of consciousness was found to be consistent with the radiologic finding of the ambient cistern on the CT scan. Complete compression of the ambient cistern was always associated with coma, a partially compressed ambient cistern with stupor or drowsiness, while a normally shaped ambient cistern was associated with a normal level of consciousness.Immediate surgical decompression of the posterior fossa was life-saving for patients with brainstem compression and upward transtentorial herniation. Mortality was 57% for comatose patients and 9% for drowsy or stuporous patients.Ventriculostomy alone is the treatment of choice in cases with only hydrocephalus without brainstem compression or transtentorial herniation.

Recurrent pituitary adenomas

SummaryBased on 880 pituitary adenomas operated upon between 1972 and 1982 the diagnostic and therapeutical strategy in recurrences is discussed. The incidence of reoperations was 7.75%, 3.7% in hormonally inactive and 4.1% in hormonally active recurrences. The rate was 30% after transcranial surgery — due to the extension of the tumours — and 5% after the trans-sphenoidal approach.In hormone inactive adenomas visual impairment in 29 out of 50 recurrences caused a second operation combined with radiotherapy in 13 cases. Radiotherapy alone was used in 17 cases.In hormonally active adenomas the treatment of persistent hormonal excess represents the main therapeutical problem. With HGH-producing adenomas a return to normal was achieved in 22 cases mainly by a combination of reoperation and radiotherapy (12) or radiotherapy (8) alone. Radiotherapy should be avoided in young patients whenever possible. The procedure of choice in PRL-procuding adenomas (14 cases) seems to be treatment with dopamineagonists (9). An additional reoperation was necessary in five cases.

The Effect of Aldosterone and an Aldosterone-Antagonist on the Metabolism of Perifocal Brain Edema in Man

Pretreatment of neurosurgical patients with either spirolactone or aldosterone shows a favourable influence on perifocal brain edema, as reflected by the results of brain tissue analysis. Data derived from animal experiments provide new information concerning the mechanism of action of both substances on CNS.

Developments in surgical treatment of pituitary adenomas

SummaryProgress in pituitary surgery has arisen with the introduction of microsurgical technique, endocrinological functional tests and computerized tomography of the skull.Using such microsurgical procedures, the transsphenoidal approach to the sella with selective adenomectomy is rendered possible. Furthermore, this operative approach is recommended also for pituitary tumours growing symmetrically to the suprasellar region.Endocrinological functional tests permit exact measurement of pituitary insufficiency and hormonal excesses, including all hormones of the anterior pituitary; today, only 30% of the adenomas are regarded as hormonally inactive. The indication to operate, the approach and the extent of the operative procedures depend on these results. Further, the operative result can be controlled by endocrine tests; in this way treatment of acromegaly can be improved: in patients with intrasellar adenomas GH-excess can be normalized in 90% of the patients.Selective adenomectomy has also improved the treatment of Cushings disease. In women with hyperprolactinemic amenorrhea, who wished to have children, ovarian cycles and pregnancy occurred. In the case of prolactinomas, for the first time medical treatment of pituitary adenomas has been successful. Computerized tomography of the skull is the most important examination in order to localize a tumour and to determine its extent whereby the operative procedure (transsphenoidal, transcranial) is decided. After operation, the radicality of the operation can thus be documented and in the case of tumour residuals a second operation may then be indicated.ZusammenfassungDie Fortschritte in der Hypophysenchirurgie basieren auf der mikrochirurgischen Technik, der endokrinologischen Funktionsdiagnostik sowie der Computer-Tomographie.Das mikrochirurgische Vorgehen hat den transsphenoidalen Zugang mit selektiver Adenomektomie ermöglicht. Darüber hinaus empfiehlt sich dieser Operationsweg auch bei symmetrisch suprasellär aus der Sella herausgewachsenen Geschwülsten.Endokrinologisch lassen sich mit Hilfe der Funktionsdiagnostik Hypophysen-Insuffizienzen und Hormon-Exzesse, die alle Vorderlappenhormone betreffen können, exakt bestimmen; als inaktiv gelten heute nur noch etwa 30% der Adenome. Von diesen Ergebnissen hängt die Indikation zur Operation, die Art und das Ausmaß des operativen Eingriffs ab. Darüber hinaus läßt sich der Operationserfolg endokrinologisch kontrollieren; auf diese Weise ist z. B. in der Behandlung der Akromegalie eine Normalisierung des GH-Exzesses bei 90% der intrasellären Adenome erreicht worden.Die selektive Adenomektomie hat auch die Behandlung des hypothalamisch/hypophysären Cushing-Syndroms bereichert und bei Frauen mit hyperprolaktinämischer Amenorrhoe und Kinderwunsch die Wiedererlangung ovarieller Zyklen und Schwangerschaften ermöglicht. Für die Prolaktinome zeichnet sich erstmals eine erfolgversprechende medikamentöse Therapie der Hypophysenadenome ab.Zur Lokalisation und Bestimmung der Ausdehnung der Geschwülste ist die Computer-Tomographie die entscheidende Untersuchung, welche die Wahl des operativen Zugangs (transsphenoidal, transkranial) bestimmt und postoperativ die Radikalität des Eingriffs belegt und im Falle verbliebener Tumorreste zu einer zweiten Operation, u. U. auf dem anderen Operationsweg, Anlaß geben kann.

Endovascular treatment of traumatic arterio-venous fistulas of the vertebral artery.

Cervical vertebral artery fistulas are rare arteriovenous malformations between the vertebral artery and veins of the neighbourhood. The etiology of the fistulas may be traumatic or spontaneous. Management and the results in two patients with large arterio-venous fistulas of the cervical vertebral artery with severe deterioration of spinal function by using the detachable balloon technique are discussed. Complete angiographic and clinical cure was achieved in both patients and no complications related to the embolization procedure occured. The detachable balloon technique is an effective method for selective occlusion of the fistula. Good radiographic monitoring facilities are required to make endovascular procedures effective and safe.

Aldosterone--A new therapeutic principle for the treatment of brain oedema in man.

SummaryA total of 47 neurosurgical patients with brain tumours have been studied. Twenty of them were not specifically treated for brain oedema before the operation and are being regarded as controls. In the other 27 patients aldosterone was given pre- and postoperatively for several days in a dose of 2×5 mg per day. During the operation, tissue samples from the vicinity of the tumour, including cortex and white matter, were removed and subjected to analysis of the following: water content, electrolytes (Na, K) and labile metabolites (CP, ATP, ADP, AMP, Pyr., Lact.). When comparing the two groups, a reduction of water content was found in the aldosterone group with a statistical significance at p 0.005. Na was at lower values in both brain compartments in the treated group, whereas K was found to be slightly elevated above the level of the controls. Metabolites showed only minor changes when the 2 groups were compared. From the clinical point of view, patients responded favourably to aldosterone therapy. In no case did treatment with aldosterone result in untoward side effects.

Extra-intracranial bypass surgery for vertebrobasilar insufficiency due to obstructive vertebral artery and vertebral-basilar artery junction disease.

This report is on 19 patients with vertebrobasilar insufficiency in whom direct extra-intracranial arterial bypass surgery to the posterior circulation was performed. In all patients preoperative angiography had demonstrated vascular lesions of haemodynamic significance of either one or both vertebral arteries (VA) or within the vertebral-basilar artery junction (VABAJ). The bypass procedure was performed between the occipital artery (OA) and - depending on the localization of the obstructive vascular lesion - the posterior inferior cerebellar artery (PICA), the VA or the anterior inferior cerebellar artery (AICA). A modification of the operative technique is presented with using a paramedian approach. The clinical results of this series support the concept that a patent extra-intracranial graft to the posterior circulation may have a protective effect by preventing further ischaemic events.

Re-Evaluation of Short-Term Steroid Therapy for Perifocal Brain Edema

Patients pre-treated with either dexamethasone or aldosterone had a considerably smoother post-operative clinical course, when compared with a placebo group, with fewer complications and an overall improved recovery rate. Unfortunately, the clinical data of this double-blind study could not be analyzed for any statistical difference since the scoring system originally developed for the patients’ neurologic examination, proved to be of only limited value when applied to the clinical situation.

Brain Revascularization Surgery for Vertebrobasilar Insufficiency Due to Obstructive Vertebral Artery Disease

Although a definitive evaluation of the benefit of brain revascularization surgery of the carotid circulation in patients with cerebrovascular insufficiency is not yet possible, encouraging results of several individual series of patients have been published. As a result, additional indications for brain revascularization procedures have been suggested, among them vertebrobasilar insufficiency (VBI). The first extra-intracranial arterial bypass (EIAB) to the posterior circulation was performed in 1975 by AUSMAN (1). Since then SUNDT and PIEPGRAS (10), KHODADAD (7), ROSKI et al. (9), and OLTEANU-NERBE et al. (8) have presented their experiences with small series of patients.