Microscopic endonasal surgery of the paranasal sinuses and the parasellar region

The anatomic principles and operative techniques currently applied to functional endoscopic endonasal surgery have allowed for significant refinements in another approach to regional pathology that uses the operating microscope, newly designed sinus instruments, and a self-retaining nasal speculum system. The main benefits of this method are the superb widefield stereoscopic vision and the distinct freedom to work bimanually. Additionally, direct bipolar cautery of bleeders is afforded while use of the observer tube or video allows for excellent teaching. The precise nature of this surgery affords less fear of serious complications in the treatment of periorbital, paranasal sinus, and parasellar diseases. We describe technical aspects of the surgery and associated complications in 219 patients treated from 1984 to 1987.     

Large colloid cyst in lateral ventricle simulating brain tumour

Summary This case report describes a patient presenting with symptoms of increased intracranial pressure, whose computerized tomographic (CT) scan was highly suggestive of a large low-grade glioma invading the basal ganglia. Magnetic resonance imaging (MRI) revealed a well-demarcated space-occupying mass of increased intensity in the left lateral ventricle and adjacent white matter. Following stereotactic biopsy, which yielded a homogeneous jelly-like material, the mass was removed microsurgically and was found to be most like a colloid cyst on histological examination. Discussion focusses on the clinical and differential diagnostic implications of this very unusual combination of findings.     

Management of hydrocephalus in children with plasminogen deficiency.

Congenital plasminogen deficiency is an infrequent disorder, which usually becomes symptomatic as ligneous conjunctivitis. However, pseudomembranous lesions in the mucosa of the pharynx, tracheobronchial tree, and the peritoneum may likewise occur. An accompanying hydrocephalus is extremely rare; only 16 cases have been reported to date. The reports indicate that hydrocephalus, even if treated by ventriculoperitoneal (VP) cerebrospinal fluid (CSF) shunting, worsens the prognosis substantially. Thus, VP CSF shunting does not seem to be the optimal therapy for hydrocephalic children with plasminogen deficiency. We add two cases to the literature, and, on the base of our experience, we propose a management strategy for the hydrocephalus. We report the case history of two children with plasminogen deficiency and associated hydrocephalus. Both children initially were treated with VP shunts and had a very similar clinical course with multiple shunt malfunctions due to nonabsorption by the peritoneum. In the first child, the attempt to treat the hydrocephalus with a ventriculoatrial (VA) shunt failed due to catheter thrombosis. Finally, a ventriculocholecystic shunt was placed in both children, which worked well. In patients with plasminogem deficiency and associated hydrocephalus, special care must be taken in the management of hydrocephalus. The absorptive capacity of the peritoneum is reduced by pseudomembrane formation, which results in VP shunt malfunction. The plasminogen deficiency results in early thrombus formation if atrial catheters are used. Therefore, the authors believe that ventriculocholecystic shunting should be considered early on in the course of the disease.     

Primary intradural pontocerebellar chordoma metastasizing in the subarachnoid spinal canal

Chordomas that are entirely extraosseous and intradural are rare. Additionally subarachnoid spinal implantation from such a cranial, intradural chordoma has never been reported before. The authors present a case of a widespread primary intradural chordoma in the basal cisterns of a 48-year-old woman which shows seeding of neoplastic cells to the spinal leptomeninges. It is concluded that also in cases of intradural and intracranial chordomas a tumor staging should include the search for spinal subarachnoid metastases.     

Modification of a mechanical twist drill trephine for craniostomy in trauma patients

A commercially available mechanical twist drill system was modified and evaluated in 35 craniotomies for frontal ventriculostomy in 31 trauma patients. The modified mechanical twist drill enabled faster and seemingly easier and safer craniotomy. It can be used as a safer alternative to common mechanical twist drill trephines, and is particularly recommended in difficult emergency conditions.     

Osteoplastic frontal sinusotomy and extradural microsurgical repair of frontobasal cerebrospinal fluid fistulas

Summary The choice of the surgical approach and operative technique for the management of cerebrospinal fluid (CSF) fistulas of the anterior cranial fossa are still a controversially discussed topic. Although extracranial approaches through the paranasal sinuses are becoming increasingly more popular among otolaryngologists and maxillo-facial surgeons, most neurosurgeons traditionally prefer the intracranial repair of CSF fistulas by a craniotomy.We present an approach through the frontal sinus for the repair of dural defects behind the posterior wall of the frontal sinus and at the floor of the anterior cranial fossa. The operative procedure comprises the following main steps: 1) exposure of the anterior wall of the frontal sinus by a bicoronal incision; 2) excision of the anterior wall without frontal burr holes; 3) bilateral removal of the posterior wall of the fronal sinus; 4) extradural inspection of the dura behind the frontal sinus and above the cribriform plate, ethmoidal roof, and orbital roof bilaterally; 5) closure of dural tears by direct suture and a periosteal graft; 6) reinsertion of the anterior wall of the frontal sinus and fixation with titanium micro plates.Twenty-five patients operated upon using this technique are described. The aetiology of the frontobasal lesion was traumatic in 23, and an ethmoid carcinoma in two. In all patients, the dural fistulas were successfully repaired during the initial procedure. One patient died from sudden circulatory arrest after an uneventful postoperative course of nine days. Otherwise, there were no postoperative complications.This technique affords atraumatic extradural inspection and repair of dural fistulas bilaterally behind the frontal sinus, and above the cribriform plate and the ethmoidal and orbital roofs with none or minimal brain retraction. It therefore allows early repair of CSF fistulas also in patients with severe brain injury. Although we consider the extradural closure of fistulas the method of choice, this approach also allows for a combined extradural-intradural procedure, thus enabling the surgeon to treat associated intradural pathologies, such as traumatic lesions or tumours of the frontal cranial base.     

A new variety of "empty sella" with cystic intrasellar dilatation of the recessus infundibuli.

A new variety of the "empty sella" consisting of polycystic intrasellar dilatation of the infundibular recess is described. The underlying embryonal developmental anomaly of the pituitary gland and diaphragma sellae and the possible effect of increased intracranial pressure are discussed and the malformation is compared with embryonal stages of ventricular development.     

Subarachnoid Haemorrhage as Initial Symptom of Multiple Brain Abscesses

The case of evolving multiple brain abscesses which became symptomatic with a sudden hemianopsia and the clinical and radiological signs of a subarachnoid haemorrhage, is reported. A common pathomechanism which could explain both the sudden focal neurological deficit and the subarachnoid bleeding is discussed.