Transpterygoid Trans-sphenoid Approach to the Lateral Extension of the Sphenoid Sinus to Repair a Spontaneous CSF Leak

OBJECTIVE AND IMPORTANCE

Cerebrospinal fluid (CSF) fistula from the middle cranial fossa into the sphenoid sinus is a rare condition. In the past, the treatment of choice has been closure via a craniotomy. Only few geriatric cases are known, which were successfully operated by endoscopic surgery. We present a further case of nontraumatic CSF fistula originating from the middle cranial fossa. A new endoscopic technique was applied. We discuss treatment options for this rare defect.

CLINICAL PRESENTATION

A 76-year-old patient presented with a 2-year history of rhinorrhea. High levels of beta-trace protein pointed to a diagnosis of CSF fistula. The defect was located at the anterior and inferior aspect of the pterygoid recess of the left sphenoid sinus.

INTERVENTION

The patient was operated using an endoscopic trans-sphenoidal approach. After endoscopic opening of the maxillary and sphenoid sinus, a complete posterior ethmoidectomy was performed. The medial part of the pterygoid process was removed, allowing endoscopic exposure and closure of the defect. At 1-year follow-up, the CSF fistula had not recurred and the patient had no sequel from the surgical procedure.

CONCLUSION

In selected cases, this new endoscopic partial transpterygoid approach to the middle cranial fossa is recommended for surgical repair of CSF fistula involving the lateral extension of the sphenoid sinus. To our knowledge, ours is the oldest patient with this condition successfully operated by endoscopic means at the world's most northern university hospital.

Introduction of endovascular embolization for intracranial aneurysms in a low-volume institution

BACKGROUND

Studies indicate a relationship between hospital caseload and health outcomes after both surgical and endovascular repair of intracranial aneurysms.

PURPOSE

To evaluate outcomes after introduction of endovascular embolization for intracranial aneurysms in a low-volume regional university hospital.

MATERIAL AND METHODS

Retrospective study of 243 consecutive patients treated for 284 intracranial aneurysms with endovascular embolization or surgical clipping from 2000 to 2006 at the University Hospital of North Norway. Postoperative complications were registered. The Glasgow Outcome Scale (GOS) was used for assessment of outcome.

RESULTS

The mean annual number of procedures was 39 (microsurgery 23, embolization 16). Seventy-four percent of patients with ruptured aneurysms and all patients with unruptured aneurysms had a favorable outcome (GOS 4 or 5) at 1 year follow-up. Patients with subarachnoid hemorrhage were more likely to experience postoperative complications than patients treated for unruptured aneurysms (42% versus 8% of the patients, P<0.01). The immediate incomplete occlusion rate (Raymond II-III) in the initial embolization procedure was 29%. Ten endovascularly treated patients and one surgically treated patient required retreatments due to residual aneurysm or neck remnants.

CONCLUSION

The present study indicates that acceptable outcome from aneurysm treatment, both endovascular and microsurgical, is possible in a low-volume institution.

[An old woman with sudden pareses and blindness]

We present a patient with Posterior Reversible Encephalopathy Syndrome (PRES). A 74-year-old woman was admitted with sepsis, which originated from erysipelas on her neck the following day. She developed respiratory obstruction due to oedema, septic shock, disseminated intravascular coagulation (DIC), acute renal failure and atrial fibrillation. She responded well to treatment and improved rapidly, despite of her serious condition. When she had almost fully recovered after 15 days, her general condition worsened, and she developed confusion, blindness and pareses. MRI showed vasogenic oedema in the parietooccipital regions of the brain and in the cerebellum, consistent with PRES. PRES is a clinical and radiological diagnosis consisting of headache, confusion, cortical blindness, convulsions and sometimes pareses. MRI of the cerebrum with diffusion-weighted imaging (DWI) and Apparent Diffusion Coefficient (ADC) map are decisive to the diagnosis, and usually shows a characteristic bilateral vasogenic oedema in the parietooccipital region. This can distinguish PRES from brain infarction, which shows a cytotoxic oedema on MRI. We discuss our patient in the light of different conditions leading to PRES, possible pathophysiological factors and treatment options.

[Treatment of intracranial aneurysms]

BACKGROUND

The department of neurosurgery at the University Hospital of North Norway has treated intracranial aneurysms since 1986. This study was conducted in order to evaluate outcomes after the introduction of endovascular therapy in 2000.

MATERIAL AND METHODS

We included all patients treated for intracranial aneurysms during the years 1999 through 2002 in a retrospective, cross-sectional study. Data were collected from patient files.

RESULTS

We treated 113 aneurysms in 104 patients in 108 procedures. 81 (78 %) patients were treated after a subarachnoid haemorrhage, while 23 (22 %) underwent treatment of an unruptured aneurysm. 75 (66 %) aneurysms were operated with craniotomy and clipping of the aneurysm neck, 38 (34 %) were treated with coiling. The choice of modality was dependent on the location and shape of the lesion. Complications related to the treatment were more common after surgical treatment than after coiling (41 versus 16 %, p=0.009), but the method of treatment did not influence long-term outcome evaluated according to the Glasgow Outcome Scale (GOS). All patients who underwent treatment for an unruptured aneurysm achieved a good outcome (GOS score 4 or 5), while patients treated after subarachnoid haemorrhage experienced significantly (p = 0.003) less favourable outcomes. Regression analysis revealed poor clinical condition (high Hunt & Hess grades) after the haemorrhage as the only independent predictor of outcome.

INTERPRETATION

The university hospital has treated an increasing proportion of patients with intracranial aneurysms with endovascular coiling after introduction of this method in 2000. The outcomes presented in this study equal those published from international multicentre trials.

Intra- and interobserver variability in the measurements of abdominal aortic and common iliac artery diameter with computed tomography. The Tromsø study

OBJECTIVES

to assess intra- and interobserver variability in the measurement of aortic and common iliac artery diameter by means of computed tomography (CT).

DESIGN

reproducibility study.

MATERIAL AND METHODS

three radiologists performed measurements of aortic diameter at five different levels and of both common iliac arteries with CT. Fifty-nine subjects were examined, 29 with and 30 without abdominal aortic aneurysms (AAA) as assessed by ultrasound.

RESULTS

intraobserver variability varied between radiologists, measurement plane (anterior-posterior vs transverse) and measurement level. The interobserver variability was markedly higher at the bifurcation than at the suprarenal level and higher than intraobserver variability for measurements at all levels. Both intraobserver and interobserver variability increased with increasing vessel diameter and were largest in patients with AAA. The absolute intraobserver difference of the maximal infrarenal aortic diameter was 2mm or less in 94% of intraobserver pairs. The corresponding interobserver difference was 82%.

CONCLUSIONS

interobserver variability of CT measurements of aortic and common iliac artery diameter is not negligible and should be taken into account when making clinical decisions. When assessing change in aortic diameter, previous CT-scans should be reviewed simultaneously as a routine to exclude interobserver variability.

[Anemia and neutropenia in primary empty sella syndrome]

BACKGROUND

A 64-year-old man was admitted to our hospital with significant weight loss and symptoms of fatigue. He had normocytic anaemia and absolute neutropenia in peripheral blood.

MATERIAL AND METHODS

Further haematological and endocrinological investigations were performed.

RESULTS

Bone marrow aspiration and biopsy showed dysplastic signs. Immunophenotyping and cytogenetics did not provide evidence of primary haematological disease. Endocrinological testing demonstrated secondary adrenal insufficiency. Magnetic resonance imaging of the sella turcica showed an empty sella. Cortisol substitution eliminated the symptoms of the patient and normalised his peripheral blood values. The disturbed maturity and hypoplasia of the bone marrow were also normalised.

INTERPRETATION

Normalisation of haematopoiesis after cortisol substitution indicates that cortisol plays an important role in the regulation of haematopoiesis. Primary empty sella syndrome with isolated ACTH cortisol deficiency is a very rare cause of disturbed haematopoiesis.

The main epidemiological, clinical and morphological features of moyamoya disease in Yugoslavia

Over a period of 22 years, 31 Moyamoya cases have been recorded in Yugoslavia. In this group of the patients comprising four children and 27 adults, peak age incidence is in the third and fourth decades of life. Males and females have been almost equally affected. Familial cases or territorial clustering of the patients have not been noted. In most cases leading symptoms on admission were motor disturbances. In four patients unilateral involvement was observed while in 27 patients bilateral changes of the internal carotid artery were seen.

Moyamoya disease in Yugoslavia: angiographic study

The angiographic findings in 31 Yugoslav moyamoya patients, 16 males and 15 females, including four children, were studied by conventional or digital subtraction angiography. The angiographic findings were reviewed for stenoocclusive lesions, form of the main cerebral arteries, transdural anastomoses, and basal vascular networks. There were 27 patients with bilaterally symmetrical or asymmetrical lesions and four with unilateral lesions. In two of these latter four patients, follow-up studies showed progression of the disease to the opposite side. Of 58 sides investigated, stenoocclusive lesions were localized above the origin of the anterior choroidal artery in 33 internal carotid arteries. Occlusions of the anterior and middle cerebral arteries were noted more frequently than stenoses: 89 vs. 27. The majority of the nests of abnormally dilated vessels (73 of 102) were localized in the ethmoidal region and basal ganglia. Analysis of distribution of the transdural collateral pathways to the brain discovered predominant participation of the middle meningeal and occipital arteries (43 of 55). Moyamoya disease in Yugoslavia predominantly affects the adult population, males and females equally, with the slowly progressive course typical for adults, and is mainly confined to the carotid fork and rarely extends to the posterior circulation.

Intracranial aneurysms associated with moyamoya disease

The authors examined 31 patients with moyamoya disease in Yugoslavia. Among them four intracranial aneurysms were disclosed, two in males and two others in females. The aneurysms, which were present in adult patients only, were diagnosed angiographically. Three of four patients died several days or weeks after onset of hemorrhage. The aneurysms were located within the basal abnormal vascular network, on a distal branch of the posterior cerebral artery, on the top of the basilar artery, and on the posterior branch of the middle meningeal artery. The moyamoya disease on the side of the individual aneurysms was most often stage III or IV.