70 ZENTRALBLATT FÜR NEUROCHIRURGIE, N° 1 À 4, 2005 : RÉSUMÉS Neurochirurgie

Conclusions. The classic hypoglossal-facial anastomosis is thetechnique of choice in most cases. The use of the intratemporalfacial nerve is indicated when removal of an intracanalar residualschwannoma must also be performed. The neurotization of thefacial muscles through a nerve graft may be used when there is nodistal trunk of the facial nerve avaible for the anastomosis.

Key-words: Hypoglossal-facial anastomosis, facial palsy, acousticschwannoma, facial nerve.

Craniotomy — A prospective analysis of predisposing factors in 100 patients

M. Engelhardt(1), S. Uhlenbruch(2), A. Christmann(3), C. Miede(3), H. Eufinger(4), M. Scholz(1), A. Harders(1), K. Schmieder(1)

(1) Neurochirurgische Klinik der Ruhr-Universität Bochum, Knappschaftskrankenhaus Bochum, Germany.(2) Klinik für Mund-, Kiefer — und Gesichtschirurgie, Plastische Operationen der Universität Essen, Germany.(3) Universität Dortmund, Fachbereich Statistik, Dortmund, Germany.(4) Klinik für Mund-, Kiefer-, Gesichtschirurgie und Plastische Operationen, Knappschaftskrankenhaus Recklinghausen, Germany.

Zentralbl Neurochir 2005; 66(2): 70-74

Object. Accidental dural tears during craniotomy constitute apossible source of CSF leakage and wound infection. This canturn an elective procedure into a complicated and cost-intensiveproblem. Only a few studies have addressed the incidence ofdural tears, but there have been many studies dealing withvarious techniques that can be employed to repair dural tears. Thepresent study was carried out to analyze predisposing factors fordural tears during trepanation in order to optimize the design of arobot-assisted trepanation system.Patients. 100 patients were analyzed prospectively. An evalua-tion sheet was designed to document size and location of thelesion and the craniotomy, the geometry and number of burrholes, and the auxiliary tools used during bone flap removal. Fur-thermore, the suspected histology was noted and anatomicalfacts, including cranial vault thickness and the presence of hype-rostosis frontalis interna, were documented.Results. In 100 craniotomies performed, in the majority of cases(64%), in order to gain access to intracerebral lesions, 30 duraltears were seen, involving both dural layers in 26 cases. Therewere 26 tears located under the margins of the craniotomy; thelength was 0-3 cm in 18 patients (69%). Significant predisposingfactors were the thickness of the cranial vault and the presence of ahyperostosis frontalis. Furthermore, the location (frontal) and thediagnosis of an extracerebral pathology, including meningiomas,were significant factors for dural tears. Elderly patients and the useof the drill to complete the trepanation were also significant predis-posing factors. Dural repair was done using suturing, in most of thecases combined with a free periostal flap. Central dural tears wereintegrated into the planned dural opening. A vascularized flap ormuscle was used in the minority of cases. Postoperative cerebralfluid leakage was seen in two patients, wound infections in three.Conclusions. Dural tears occurring during craniotomy cannot beprevented, when predisposing factors are taken into account. Theabsence of brain damage may due to two factors: 1) in elderlypatients with hyperostosis, an additional atrophy of the brain ispresent; 2) extracerebral tumors, with their space-occupyinggrowth, shift the underlying brain away from the calvaria. Consi-dering the design of a robot-assisted trepanation system, thefollowing conclusions seem possible: Dural tears cannot be

avoided because predisposing factors are overriding. For impro-ved safety, additional, specialized instrumentation is required.

Key-words: Dural tear, trepanation.

Ethical aspects of use of fetal/embryonic cells in treatment and research

H. Watt

Linacre Centre for Healthcare Ethics, London, United Kingdom.

Zentralbl Neurochir 2005; 66(2): 75-78

The use of cells derived from in vitro embryos or aborted humanfetuses raises serious moral questions for doctors and researchers.It is not enough to anticipate good from such use: morality isconcerned not merely with outcome, but with choices and theirimpact on character. The human moral subject is the human orga-nism, who has rights and interests from the beginning of his orher existence. Harvesting cells or tissue from an embryo or fetuswho is deliberately destroyed — in some cases, by the harvestingitself — is a violation of the rights of the individual concerned.To accept cells or tissue from those who did the harvesting (asopposed to using a much older cell-line) is to give the impressionthat we condone the harvesting, and indeed the taking of thedonor’s life. Irrespective of the medical benefits for which wemay be hoping, we cannot relieve the suffering of one humanindividual by exploiting another.

Key-words: Embryo, fetus, cell-line, fetal tissue, embryonic stem cells,complicity.

Recommendations for the management of patients with aneurysmal subarachnoid hemorrhage

A. Raabe(1), J. Beck(1), J. Berkefeld(2), W. Deinsberger(3), J. Meixensberger(4), P. Schmiedek(5), V. Seifert(1), H. Steinmetz(6), A. Unterberg(7), P. Vajkoczy(5), C. Werner(8)

(1) Klinik und Poliklinik für Neurochirurgie, Klinikum der Johann-Wolfgang-Goethe-Universität Frankfurt am Main, Germany.(2) Institut für Neuroradiologie, Klinikum der Johann-Wolfgang-Goethe-Universität Frankfurt am Main, Germany.(3) Neurochirurgische Klinik, Universitätsklinikum Gießen, Germany.(4) Neurochirurgische Klinik, Universität Leipzig, Germany.(5) Neurochirurgische Klinik, Klinikum Mannheim, Germany.(6) Klinik für Neurologie, Klinikum der Johann-Wolfgang-Goethe-Universität Frankfurt am Main, Germany.(7) Neurochirurgische Klinik, Ruprecht-Karls-Universität Heidelberg, Germany.(8) Klinik für Anästhesiologie, Klinikum der Johannes-Gutenberg-Universität Mainz, Germany.

Zentralbl Neurochir 2005; 66(2): 79-91

After SAH, primary and secondary complications are frequent andoften require neurosurgical interventions to avoid secondary braindamage. The authors of the present paper have summarized theavailable data about the treatment modalities often used for patientswith SAH. The present recommendations have been developed as aneurosurgical and neuroanestesiological consensus. Evidence fromprospective, randomized, double blind, placebo-controlled studiessupport grade A recommendations (standard) for the prophylaxisand treatment of cerebral vasospasm with oral Nimodipine in goodgrade patients. For intravenous Nimodipine or for oral nimodipinetreatment in poor grade patients, available data only support grade C

Vol. 52, n° 1, 2006 ZENTRALBLATT FÜR NEUROCHIRURGIE, N° 1 À 4, 2005 : RÉSUMÉS 71

recommendations (options). Despite the lack of data supporting stan-dards (grade A) or guidelines (grade B), avoidance and rigoroustreatment of hypotension and hypovolemia remains the mainstay inthe prophylaxis and treatment of a delayed ischemic neurologicaldeficit (DIND). Prophylactic hypervolemia or prophylactic hyper-tension and hypervolemia was shown to be ineffective in reducingsymptomatic vasospasm and improving outcome (grade B). Thera-peutic hypertensive hypervolemic hemodilution is recommended asa treatment of symptomatic vasospasm but no prospective studies areavailable (grade C recommendation). Suggested target values formoderate triple-H-therapy are CPP 80— 120 mmHg (MAP 90-130),CVP >7 mmHg and Hk 0.25-0.40. Balloon angioplasty should beconsidered for treatment of DIND cause by focal, proximal cerebralvasospasm. There is no evidence supporting the routine use of anti-fibrinolytica, steroids or anticonvulsive prophylaxis. Clinical dataindicate that current prophylaxis and treatment of cerebral vaso-spasm is still insufficient and aggressive triple-H-therapy is associa-ted with an increased incidence of complications.

Key-words: Subarachnoid hemorrhage, rebleeding, cerebral vasospasm,triple-H-therapy.

Ceftriaxone-induced symptomatic pseudolithiasis mimicking ICP elevation

C. Evliyaoglu(1), T. Kizartici(2), G. Bademci(1), B. Unal(3), S. Keskil(1)

(1) Department of Neurosurgery, Kirikkale University School of Medicine, Kirikkale, Turkey.(2) Consultant, County Hospital, Odemis, Turkey.(3) Department of Radiology, Kirikkale University School of Medicine, Kirikkale, Turkey.

Zentralbl Neurochir 2005; 66(2): 92-94

In neurosurgery, ceftriaxone is a widely used, third generationcephalosporin for the treatment of CNS infections and periopera-tional prophylaxis. Recent studies have demonstrated thatceftriaxone induces reversible precipitates in the gallbladder.This complication is referred to as “biliary pseudolithiasis”, andit has symptoms similar to the raised intracranial pressure (ICP)symptoms of the perioperative period. Symptomatic biliary pseu-dolithiasis should be kept in mind in all pediatric neurosurgerycases under ceftriaxone therapy in order to prevent unnecessarypostoperative investigations and surgery.

Key-words: Cephalosporin, antibiotic prophylaxis, children, surgery.

Tuberculosis of the craniocervical junction: a case report

F. Torun(1), H. Tuna(1), M. Bozkurt(1), E. Dusunceli(2), H. Deda(1)

(1) Department of Neurosurgery, Ankara University, Faculty of Medicine, Sihhiye, Ankara, Turkey.(2) Department of Radiology, Ankara University, Faculty of Medicine, Sihhiye, Ankara, Turkey.

Zentralbl Neurochir 2005; 66(2): 95-97

Craniocervical tuberculosis (TB) is very rare. Despite the use ofmagnetic resonance imaging (MRI) and cranial tomography(CT), diagnosis of craniocervical tuberculosis is frequently diffi-cult. In this study, we present a craniocervical tuberculosisabscess case which demonstrates the role of transoral surgery forboth diagnosis and treatment.

Key-words: Craniocervical junction, transoral surgery, tuberculosis abscess.

Motor evoked potentials following highly frequent transcranial magnetoelectrical motor cortex stimulation: normal data and potential modulation by stimulation-dependent inhibitory and activating mechanisms

V. Rohde, M. Neubert, P. Reinacher, M. Weinzierl, I. Kreitschmann-Andermahr, J.M. Gilsbach

Neurochirurgische Klinik, Medizinische Fakultät, Universität Aachen, Germany.

Zentralbl Neurochir 2005; 66(3): 105-111

Objective. To determine the normal values (latency, amplitude) ofmotor evoked potentials (MEP) of the abductor pollicis brevis (APB)and tibialis anterior (TA) muscle after high-frequency repetitivetranscranial magnetic stimulation of the motor cortex (rTCMS), andto evaluate stimulation-dependent MEP modulations.Patients and methods. 29 healthy volunteers underwent rTCMSwith 2 and 4 stimuli. The interstimulus interval (ISI) was 2, 3,and 4 ms respectively, which corresponded to frequenciesbetween 250 and 500 stimuli/s. The evoked potentials of therelaxed and voluntarily contracted APB and TA were registered.Results. Depending on the frequency and number of stimuli, themean corticomuscular latency to the relaxed APB varied between22.2 and 22.9 ms, and to the relaxed TA between 30.4 and 32.0 ms.The intra- and interindividual variability of the amplitudes wassubstantial. Voluntary contraction of the target muscle always ledto a decrease in latency and increase in amplitude (p<0.05).Conclusion. The high variability of the amplitudes does not allowthe computation of meaningful normal values. The latencies afterrTCMS are close to those of normal data after single TCMS, whichindicates that in awake humans identical cortical and spinal struc-tures are similarly activated. The discrete variations of latency andamplitude after changing the frequency and stimulus number sug-gest that inhibitory and excitatory mechanisms on the cortical and/or spinal level modulate the muscle response.

Key-words: Magnetic stimulation, motor cortex, transcranial motor cor-tex stimulation, motor evoked potentials, MEP.

Neurological and psychosocial outcome after subarachnoid haemorrhage, and the Hunt & Hess scale as a predictor of clinical outcome

C. Cedzich(1), A. Roth(2)

(1) Clinic of Neurosurgery, Klinikum Süd Nürnberg, Academic Hospital, University of Erlangen-Nürnberg, Germany.(2) Cand. med., Klinikum Süd Nürnberg, Academic Hospital, University of Erlangen-Nürnberg, Germany.

Zentralbl Neurochir 2005; 66(3): 112-118

In a retrospective study, the outcome of 87 patients with rupturedintracranial aneurysm was assessed. Follow-up included neurologi-cal examination, grading of the Glasgow Outcome Scale (GOS) ofeach patient, and answering a psycho-social questionnaire. Thisquestionnaire was answered by the patients themselves or by a rela-tive when the patient was not able to answer. The follow-up wasperformed more than 12 months after the occurrence of subarach-noid hemorrhage (SAH) in each patient. The psycho-social question-naire pertained to the degree of independence in everyday activities,household management, stress endurance, memory and concentra-tion, social and leisure activities, social contacts, occupational status,and marital relationships. By summarizing the results of these