Magnetic resonance imaging of dysraphic myelodysplasia

The spinal cord in 56 children and adolescents was examined by magnetic resonance imaging (MRI) many years after neonatal surgery on a meningomyelocele (average age 12 years). In a high percentage of cases, the diagnosis "tethered cord" was made. Associated anomalies were found with a frequency of 21%. Typical findings are presented and the impact of these results on therapy planning is discussed.

Bovine pericardium for duraplasty: clinical results in 32 patients.

Bovine pericardium has been widely used for grafts in cardiac surgery and seems to have suitable properties for use as a dural graft. We report on the use of solvent-preserved, gamma-sterilized Tutoplast bovine pericardium for dural grafts in 32 patients undergoing cranial and spinal operations with the objective of clinically assessing this material and technique by a retrospective analysis. All available records were reviewed and information regarding the indication for grafting, complications, and outcome were collected and analyzed for all patients. Indications for grafting included tethered cord myelolysis, closure of lumbosacral myeloceles, Chiari decompression, posterior fossa cranio…

Endo-neuro-sonography: principles and 3-D technique

To evaluate the usefulness of transendoscopic sonography we studied two new sono probes 6 F in diameter in 17 fresh specimens. We saw precise imaging of well-known anatomical structures and also gained an additional dimension in endoscopy, as the sono adds to the endo-view a transverse scan like a mini-CT at the tip of the probe. We also experienced the navigation characteristic of this imaging technique, both in real time and on line. Some 3-D reconstructions of the ventricular system were examined. The equipment has been used in clinical practice and must now be adapted for neurosurgery.

Change of hands - change of format

Orthopedic and neurosurgical treatment of severe kyphosis in myelomeningocele

Kyphosis in myelomeningocele is characterized by a complex pattern of problems during development and therapy. On the one hand, decompensation of upright posture leads to loss of sitting ability and social integration; on the other hand, accompanying malformations and trophic alterations threaten the physical integrity and performance. Neurologic function, cerebrospinal fluid (CSF) circulation, skeletal deformity and the urinary transport system need to be kept in mind and need to be treated with cooperation between the different specialties. Especially during serious surgical interventions such as spinal surgery, neither the nervous system nor the kidneys must be ignored. Sixteen patients …

Long-term follow-up of children with magnetic resonance imaging and ultrasound after treatment of brain tumors

This paper compares the results of MRI and US follow-up examinations of 46 children who had undergone surgery for brain tumors. The cases included 42 posterior fossa tumors, 3 supratentorial tumors and 1 upper cervical spinal cord tumor. US examination proved to be less specific and sensitive than MRI. However, when a "bone window" is available, US is, because of the ease of its application, better suited for frequent routine examinations. Long-term follow-up should, therefore, consist of frequent regular US examinations combined with yearly MRI examinations.

Prevention of deep vein thrombosis in neurosurgical patients: a prospective double-blind comparison of two prophylactic regimen.

In a prospective, randomized, double-blind investigation of anticoagulant agents for prevention of deep vein thrombosis in patients undergoing operations at the lumbar-vertebral disc, 179 patients were randomly allocated to two groups. 87 patients received a fixed combination of low-molecular weight heparin 1,500 U-aPTT plus dihydroergotamine 0.5 mg (LMWH/DHE) once a day and additionally one injection of placebo per day, 92 patients received a fixed combination of sodium heparin 5,000 U plus dihydroergotamine 0.5 mg (HDHE) twice a day. Treatment was initiated two hours preoperatively in both groups and continued for at least seven days. Deep vein thrombosis (DVT), detected by the 125Iodine-…

Fine structural features of the cerebral microvasculature in hydrocephalic human infants: correlated clinical observations.

Four of 30 human cerebral cortex biopsies from infants ranging from four days to about ten years treated for hydrocephalus by shunt operations are described paying special attention to the vascular structures. The biopsy specimens were studied in semi-thin and ultrathin sections. Attention is drawn to the role of pinocytotic vesicles found in capillaries and smaller vessels as a possible transcellular route for the hydrocephalic oedema resolution. No intercellular dehiscences or the so called blisters were observed. With the passage of time, the number of membrane bound vesicles increased and arrays of pinocytotic vesicles were discernible both on the abluminal as well as luminal aspect of …

Development of scoliosis in myelomeningocele. Differences in the history caused by idiopathic pattern.

The natural history of scoliosis in the literature concerning the idiopathic and neuromuscular scoliosis in myelomeningocele patients (MMC) are compared to our own results in 12 patients with MMC and 89 patients operated because of an idiopathic scoliosis. According to known experiences the natural history of scoliosis in MMC is progression even after the end of growth. The chance of developing a scoliosis increases with the patients, age and the level of the lesion. The higher the level of paralysis the more common is a spinal deformity. In literature the progression rate of MMC scoliosis is 2.5-3.5 degrees per year, with the idiopathic pattern 0.5-0.65 degrees per year after end of growth…

Antibiotic single-dose prophylaxis of shunt infections.

Shunt infections after implantation or revision of a shunt for CSF drainage in hydrocephalic patients are serious complications. In view of their frequency, this study investigated the efficacy of prophylactic administration of a single dose of the antibiotic cefazedone in reducing in the post-operative infection rate. Fifty children of up to 14 years of age suffering from hydrocephalus of various etiologies were treated prophylactically and compared with a similar untreated group. The diagnosis of infection was based mainly on microbiological and clinical observations and investigations. Classical infection parameters were also recorded and evaluated, but played only a secondary role in es…

Clinical and ultrastructural observations of maturing human frontal cortex. Part I (Biopsy material of hydrocephalic infants).

Three of 30 human cerebral cortex biopsies from infants treated for hydrocephalus by shunt operation are described. The descriptions include an account of their case history, the clinical methods, and the operational procedures. The biopsy specimens were studied in semithin and ultrathin sections. Attention is drawn to normal synapse formation but also to neuronal degenerative changes due to hydrocephalus.

Cerebral arachnoid cyst: a lesion of the child's brain.

39 patients with 42 arachnoid cysts have been reviewed in a retrospective study. All kinds of arachnoid cysts reported in the literature were also found in this study. These consist mainly of congenital primary and post-traumatic secondary cysts. Cysts which cause no major neurological deficits require conservative treatment of symptoms only. Cysts which cause major symptoms because of their space occupying nature, however, require surgical treatment. Craniotomy with removal of membranes to allow free physiological circulation of CSF is the treatment of choice in our hands. Cysto-peritoneal shunting is an alternative procedure for patients in a poor condition. More than 50% (23 out of 39 ca…

Assessment of brainstem function in Chiari II malformation utilizing brainstem auditory evoked potentials (BAEP), blink reflex and masseter reflex

Brainstem dysfunction was evaluated in 67 patients with myelomeningocele and Chiari II malformation using brainstem auditory evoked potentials (BAEP), blink reflex (BR) and masseter reflex (MR). Signs and symptoms related to Chiari II malformation were observed in 18 patients while 49 patients had normal brainstem findings. BAEP and BR showed a higher sensitivity of brainstem involvement than MR (BAEP=1.0, BR=0.83, MR=0.50). BR, and in particular, MR were of higher accuracy (BR=0.52, MR=0.72) than BAEP (0.39) in separating patients with brainstem signs and symptoms related to Chiari II malformation. We feel that this is due to anatomic and physiologic peculiarities of the brainstem structur…

Arachnoid cysts: does surgery improve epileptic seizures and headaches?

During the period from 1985 to 1992 we treated 43 patients with intracranial arachnoid cysts (ACs). In this retrospective study we assessed the outcome of these patients with regard to non-specific symptoms such as headaches and epileptic seizures. Twelve patients had headaches of obscure origin and a mostly temporal located AC. Six of these 12 underwent surgery. After the operation 4 patients (4/6) had no further headaches, two remained unchanged. The other 6 conservatively treated patients (6/12) had further headaches. Ten of the 43 patients had epileptic seizures. One patient dropped out of the survey. Six of the 9 remaining patients had a temporal AC. Four of these 6 underwent surgery; …

MRI studies after treatment of brain tumors in childhood and adolescence

Forty-seven children and adolescents with brain tumors were examined by magnetic resonance imaging (MRI) after tumor resection. The typical changes and complications after surgery and chemotherapy, as well as the corresponding MRI findings, are discussed. Typical examples of boundary-layer lesions, tumor recurrences, hydrocephalus, porencephalic cysts, and hygromas are given.

Surgical treatment of posterior fossa tumors in infancy and childhood: techniques and results

In a collective of 72 children with tumors of the posterior fossa, the preoperative diagnosis, operation planning and performance, and use of additional procedures, like the preliminary ventricular drainage and interventriculostomy are described. The extent of intra- and postoperative complications is given. Postoperative lethality was 0% in the group operated on between 1979 and 1991. The responsible factors are discussed. The findings support the opinion of ALBRIGHT (1989) that the prognosis for such patients is most promising in the hands of a specialist in pediatric neurosurgery.

Somatosensory evoked potentials in Arnold-Chiari malformation.

Abstract Nearly all patients with repaired myelomeningoceles have an Arnold–Chiari (AC) malformation and about 20% of these patients develop clinical signs of brainstem dysfunction. The management of symptomatic AC malformation is still controversial and techniques are needed to provide an objective assessment of brainstem function. We recorded somatosensory evoked potentials (SEPs) in 52 patients aged between 8 months and 20 years (median 7.3 years) with AC malformation, to determine whether the SEPs discriminate patients with symptomatic AC malformation from those without symptoms. The subcortical far-field components P13, P14 and N18, which are generated within the brainstem, were record…

Arterio-venous malformations in childhood: Clinical presentation, results after operative treatment and long-term follow-up

In a series of 182 arterio-venous malformations (AVM) recently published [8] we found 33 children aged 1 to 16 years. In 28 cases, the admitting condition was hemorrhage. For 31 AVMs total excision was possible. We observed one postoperative death accounting for a mortality of 3%. All children but two were followed-up by personal examination. Two were not able to work due to severe neurological deficits and seven had not been able to get into their intended occupation.

CSF shunt infections in children

The incidence of shunt infections and possible risk factors was investigated by chart analysis. From 1986 to 1989 350 shunt procedures were performed including 273 ventriculoperitoneal shunts and 75 ventriculoatrial shunts. Twenty-eight infectious episodes (8%) occurred in 25 patients during a median follow-up time of 20 months. For 204 patients the follow-up time could be prolonged until September 1992. In these patients no infectious episodes occurred in the extended observation period. In 24 cases (85.7%) a causative organism could be isolated. The infecting organisms were gram-positive cocci in 22 cases (78.6%) and gram-negative bacilli in two cases. The main signs and symptoms were fev…

Arachnoid cysts: How do postsurgical cyst size and seizure outcome correlate?

Arachnoid cysts (ACs) are congenital cystic brain malformations associated with epilepsy. The purpose of this study was to determine the effect of surgical intervention of ACs on cyst size and seizure outcome. We reviewed the world's medical literature dealing with surgically treated ACs in epilepsy patients. Our study included only cases, in which the relationship between pre- and post-operative CT-size of the AC and seizure outcome was described. We also included six patients with ACs and epilepsy treated surgically at the University of Mainz. We analyzed postoperative AC size and seizure outcome with respect to mode of operation, cyst location, and patients' age. A total of 76 patients w…

Magnetic resonance imaging of postrepair-myelomeningocele — findings in 31 children and adolescents

Magnetic resonance imaging has clearly demonstrated its efficacy in the diagnosis of pathological processes in the C.N.S. We examined 31 children who had undergone plastic closure of myelomeningocele a few days post partum. We could show that a high percentage of the patients (89%) presented the pathological anatomy of a tethered spinal cord; clinical symptoms of the tethered spinal cord syndrome, i.e. progressive neurological symptoms, however, are rarely observed. Possible revision of neurosurgical treatment of MMC is discussed.

Masseter reflex and blink reflex abnormalities in Chiari II malformation.

Masseter reflex and blink reflex were evaluated in 64 patients with a myelomeningocele and Chiari II malformation. In 46 patients, no brainstem signs or symptoms were present. Brainstem dysfunction related to Chiari II malformation occurred in 18 patients. The masseter reflex was more frequently abnormal in the symptomatic than asymptomatic patients (P = 0.02). Although the blink reflex was similarly affected in the two groups of patients (P > 0.1), it was very sensitive, being abnormal in 83% of symptomatic and 65% of asymptomatic patients. Concomitant abnormality of masseter reflex and the late contralateral blink reflex component (R2c) was almost exclusively found in symptomatic patients…