The rate of complications in patients with cSDH who underwent the BCD is high. The clinical relevance of medical complications has to be emphasized because of their substantial contribution to overall mortality.

To present a large series of surgically treated tuberculum sellae meningiomas with particular regard to involvement of the optic canal and visual outcome. Methods: A retrospective analysis was done on 53 patients (40 female) with meningiomas originating from the tuberculum sellae who underwent surgery between 1991 and 2002. The standard surgical approach consisted of pterional craniotomy. Sixteen meningiomas extended posteriorly onto the diaphragma sella, 29 anteriorly to the planum sphenoidale, and 19 to the anterior clinoid process. Thirty seven tumours involved the optic canal, three bilaterally. Follow up ranged from 6 to 108 months (mean 29.9 months). Results: Total macroscopic resection was achieved in 48 patients. Median tumour size was 2.6 cm. Postoperatively, visual acuity improved in 20 patients and deteriorated in seven. Preoperative and postoperative visual acuity worsened with increasing duration of preoperative symptoms and with increasing age. Extension into the intraconal space was a negative predictor. However, tumour size did not influence visual acuity. Recurrence occurred in two cases (21 and 69 months postoperatively). Two patients died from causes unrelated to the tumour. Conclusions: In the majority of patients with tuberculum sellae meningiomas, total resection may be achieved through a pterional approach with minimal complications.

Approximately 34 cases of intracranial tuberculomas with paradoxical response to antituberculous chemotherapy have been documented worldwide. In most of the previously reported cases an associated tuberculous meningitis was reported. The majority of these patients were children or young adults, who had inoperable intracranial tuberculomas located in high risk regions that developed a few weeks or months after the start of an appropriate chemotherapy. Fifty-three percent of the patients recovered completely, 37% improved with mild neurological defects and 10% died. It is interesting that these intracranial tuberculomas developed or enlarged at a stage when systemic tuberculosis was being treated successfully. A recent experience with these potentially curable tumors of the central nervous system is reported. The literature is reviewed, and diagnostic and therapeutic considerations are discussed. The possible immunological mechanisms of this phenomenon are analyzed. In conclusion, patients who are suspected to have a CNS-tuberculosis should receive a prolonged (12-30 months) course of effective antituberculous therapy. The evidence of new intracranial tuberculomas or the expansion of older existing lesions does not indicate the need to change the antituberculous drug program. In such cases systemic dexamethasone as adjuvant therapy for 4 to 8 weeks is worthwhile and effective. Surgical intervention may be necessary in situations with acute complications of CNS tuberculosis, such as shunting procedures for the treatment of hydrocephalus. When the diagnosis is not ensured and there is no response to therapy within 8 weeks, a stereotactic biopsy on a suspected tuberculoma could be performed. If the largest lesion is not located in high risk deep regions of the brain, it could be totally removed surgically. With this combined management, a satisfactory outcome can be obtained in the majority of cases.

Local hemodynamics were investigated during nine operations for spinal dural arteriovenous (AV) fistulas. In eight cases, microvascular Doppler sonography was used to measure flow velocities and vasomotor reactivity to CO2 changes. Intravascular pressure recordings of the draining veins on the medullary surface were performed in nine cases. The flow velocities in dural AV fistula feeding vessels were not as high as has been shown in cerebral angioma feeders. The AV fistula feeders often showed low end-diastolic flow velocities as a sign of increased vascular resistance, even in the presence of a downstream AV fistula, thus proving disturbance of venous outflow from the spinal canal. After excision of the fistula, the circulation of the spinal cord vessels improved, with higher inflow and outflow velocities. In the veins formerly draining the fistula, no further flow could be recorded; however, they did not collapse, indicating that some pressure remained. The mean venous pressure in the dural AV fistulas was about 74% of the systemic arterial pressure. It increased concomitantly with the arterial pressure, which may explain the clinical deterioration that occurs during physical activity. Fistulas with a high shunt volume on angiography showed only moderately increased venous pressures and a more pronounced pressure drop compared to low-volume fistulas. The CO2 reactivity of vessels supplying the spinal cord could be demonstrated in all cases, and was normal before and after removal of the fistula.

To investigate the hemodynamics of intracranial circulatory arrest, the authors correlated the findings of noninvasive transcranial Doppler ultrasonography (TCD) with those of transfemoral four-vessel angiography in 65 patients following brain death and intracranial circulatory arrest due to severe intracranial hypertension. The three TCD stages of intracranial circulatory arrest, which have been described previously, corresponded with different levels of extracerebral angiographic cessation of flow. With TCD progression from the first stage (oscillating flow) to the third stage (no flow), the level where the dye stopped descended caudad from subarachnoid to cervical levels. The study shows that, in progressing intracranial hypertension, arterial circulatory standstill within the cranial cavity develops in a distal-to-proximal direction. The basal cerebral arteries remain patent in the early stages of intracranial circulatory arrest. Experimental evidence from the literature, together with the findings of the present investigation, points to the capillary bed as the initial site of the flow obstruction in progressing intracranial hypertension.

Six patients were observed during recurrent subarachnoid hemorrhage (SAH). Three each had an open skull and intact dura mater and demonstrated an extreme increase in intracranial pressure (ICP) that developed within 1 minute and then declined over several minutes. Three other patients were investigated with transcranial Doppler sonography before, during, and after recurrent bleeding, and their hemodynamics were studied. There is conclusive evidence that acute spontaneous SAH is often followed by an intracranial circulatory arrest lasting for several minutes and caused by a peak of ICP in the range of mean arterial levels. The mechanisms involved are discussed. There are strong indications that this temporary intracranial circulatory arrest promotes hemostasis, but may constitute a severe ischemic event.

The goal of surgery is complete tumor removal without morbidity. An exact analysis of tumor growth and its involvement of different structures is mandatory before performing surgery.

Background?Olfactory groove meningiomas remain surgically challenging. The common microsurgical approaches suffer from late exposure of the neurovascular structures. Conversely, the pterional approach has the advantage of early dissection of the posterior neurovascular complex. Methods?We reviewed the records of patients treated for olfactory groove meningioma in our department between 1991 and 2010. A total of 61 patients underwent removal of olfactory groove meningiomas via the pterional approach. These included 58 primary and 3 recurrent tumors. Mean overall follow-up time was 122 months. Results?Early exposure and dissection of the internal carotid artery, middle cerebral artery, anterior cerebral artery, and optic nerve was feasible in all cases. Complete tumor removal was achieved in 60 patients. Morbidity and mortality rates were 26% and 1.6% respectively. Postoperative complications included epileptic seizures (five patients) and cerebrospinal fluid (CSF) leak (two patients). During follow-up, we recorded three tumor recurrences. Conclusions?The pterional approach appears to be an excellent solution for the treatment of olfactory groove meningiomas. Its foremost advantage is early visualization of the posterior neurovascular complex. Moreover, it allows frontal sinus preservation and timely tumor devascularization and avoids excessive brain retraction. The pterional view is familiar to most neurosurgeons and therefore the transition to this technique is fairly straightforward.