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Biomedical subjects

R Fahlbusch

Publications and source records attributed to R Fahlbusch.

At least 91 records · Page 5Linked to original sources
PubMed1999

Expression of menin gene mRNA in pituitary tumours.

OBJECTIVE: Multiple endocrine neoplasia type 1 (MEN 1) is an autosomal dominant inherited disorder characterised by the combined occurrence of parathyroid, endocrine pancreas and anterior pituitary tumours. The gene responsible for MEN 1, the menin gene, a putative tumour-suppressor gene located on human chromosome 11q13, has been cloned. To investigate the role of the menin gene in sporadic anterior pituitary tumorigenesis, its mRNA was assessed in a group of pituitary tumours. METHODS: Menin gene expression, along with glyceraldehyde phosphate dehydrogenase (GAPDH) gene expression, has been studied in a group of normal pituitaries and in 23 pituitary tumours not associated with the MEN 1 syndrome. The pituitary tumours included 4 prolactinomas, 11 growth-hormone-secreting tumours and 8 non-functional tumours. Total RNA was extracted from the normal pituitaries and tumours, and cDNA was synthesised with standard reverse transcriptase methods. Duplex polymerase chain reaction (PCR) was standardised in order to quantify the expression of the menin gene using intron-spanning primers across exons 9 and 10 in relation to the 'house-keeping' gene GAPDH. The PCR products were separated on agarose gel and densitometric analysis of the bands allowed semi-quantification. RESULTS: There was no evidence for a change in menin gene expression in any of the pituitary tumours when compared with normal pituitaries. CONCLUSIONS: These studies complement previous work on mutational analysis, and do not suggest a major role for the menin suppressor gene in sporadic pituitary tumorigenesis.

DNA Primers↗
PubMed1999

Surgical treatment of craniopharyngiomas: experience with 168 patients.

OBJECT: The goal of this study was to assess the outcome of surgical management in 168 consecutive patients harboring craniopharyngiomas treated between January 1983 and April 1997. METHODS: In 148 patients undergoing initial (primary) surgery, the pterional approach was most frequently used (39.2%), followed by the transsphenoidal approach (23.6%). For large retrochiasmatic craniopharyngiomas, the bifrontal interhemispheric approach was used increasingly over the pterional approach and led to improved surgical results. Total tumor removal was accomplished in 45.7% of transcranial and 85.7% of transsphenoidal procedures. The main reasons for incomplete removal were attachment to and/or infiltration of the hypothalamus, major calcifications, and attachment to vascular structures. The success rate in total tumor removal was inferior in the cases of tumor recurrence. The operative mortality rate in transcranial surgery was 1.1% in primary cases and 10.5% in cases of tumor recurrence. No patient died in the group that underwent transsphenoidal surgery. The rate of recurrence-free survival after total removal was 86.9% at 5 years and 81.3% at 10 years. In contrast, the 5-year recurrence-free survival rate was only 48.8% after subtotal removal and 41.5% after partial removal. Following primary surgery, the actuarial survival rate was 92.7% at 10 years, with the best results after complete tumor removal. At last follow up, 117 (79%) of 148 patients who underwent primary surgery were independent and without impairment. CONCLUSIONS: Total tumor removal while avoiding hazardous intraoperative manipulation provides favorable early results and a high rate of long-term control in craniopharyngiomas.

Adolescent↗
PubMed1999

Surgical treatment of craniopharyngiomas: endocrinological results.

OBJECT: This study aimed to elucidate the endocrinological outcome of craniopharyngioma surgery. In particular, endocrinological results were analyzed in relation to the surgical approach. The study includes 143 patients who underwent pre- and postoperative endocrinological assessment and who had not previously undergone surgery. METHODS: Diabetes insipidus was the most common postoperative deficiency in both the transcranial and transsphenoidal groups. The overall percentage of patients with diabetes insipidus increased from 16.1% preoperatively to 59.4% postoperatively. After transcranial surgery, the rate of anterior pituitary deficiency also increased. However, normal preoperative anterior pituitary function was maintained in more than 50% of patients for each endocrine axis. Similar results were attained in the group of patients undergoing complete tumor removal. The best result was achieved for gonadal function: the incidence of hypogonadism increased only slightly from 77.4 to 79.8%. The rate of anterior pituitary failure at presentation was much higher in the transsphenoidal than in the transcranial group. During transsphenoidal surgery, intact anterior pituitary functions were generally preserved. The rate of panhypopituitarism increased only slightly, from 40% before surgery to 42.9% after surgery. Endocrinological results were not inferior in patients with a ventrally displaced pituitary. This variant required midline incision of the gland for exposure of the craniopharyngioma. In the entire series of 143 patients the pituitary stalk was generally preserved. Postoperative panhypopituitarism was encountered in only one of eight patients in whom the pituitary stalk was partially resected because of tumor infiltration. None of the 88 patients who remained recurrence-free demonstrated endocrinological deterioration during follow-up review, compared with the early postoperative assessment 3 months postsurgery. On the other hand, complete recovery of one endocrine axis was observed in nine of these patients during later follow-up evaluations. In five of them, diabetes insipidus had regressed. CONCLUSIONS: It is worth preserving the pituitary stalk and gland at surgery because of the definite chance that intact anterior pituitary functions can be maintained. Postoperative diabetes insipidus must be accepted as a common sequela following attempts at complete removal of the craniopharyngioma.

Adolescent↗
PubMed1999

Middle ear adenocarcinoma with intracranial extension. Case report.

Middle ear adenocarcinoma is a very rare, locally invasive neoplasm assumed to arise from the middle ear mucosa. Although endolymphatic sac tumor (aggressive papillary middle ear tumor) and jugulotympanic paraganglioma may show brain invasion, intracranial extension of histologically confirmed middle ear adenocarcinoma has not been previously reported. The authors describe a 53-year-old man who suffered from otalgia and tinnitus for more than 10 years and from neurological deficits for 1 year due to a large temporal bone tumor that invaded the temporal lobe. A combined neurosurgical and otolaryngological resection was performed. Pathological analysis revealed a low-grade adenocarcinoma of a mixed epithelial-neuroendocrine phenotype, which showed a close histological similarity to, and topographical relationship with, middle ear epithelium. The authors conclude that middle ear adenocarcinoma belongs to the spectrum of extracranial tumors that have possible local extension to the brain.

Adenocarcinoma↗
PubMed1999

Functional neuronavigation with magnetoencephalography: outcome in 50 patients with lesions around the motor cortex.

OBJECT: The authors conducted a study to evaluate the clinical outcome in 50 patients with lesions around the motor cortex who underwent surgery in which functional neuronavigation was performed. METHODS: The sensorimotor cortex was identified in all patients with the use of magnetoencephalography (MEG). The MEG-source localizations were superimposed onto a three-dimensional magnetic resonance image and the image data set was implemented into a neuronavigation system. Based on this setup, the surgeon chose the best surgical strategy. During surgery, the pre- and postcentral gyri were identified by neuronavigation and, in addition, the central sulcus was localized using intraoperative recording of somatosensory evoked potentials. In all cases MEG localizations of the sensory or motor cortex were correct. In 30% of the patients preoperative paresis improved, in 66% no additional deficits occurred, and in only 4% (two patients) deterioration of neurological function occurred. In one of these patients the deterioration was not related to the procedure. CONCLUSIONS: The method of incorporating functional data into neuronavigation systems is a promising tool that can be used in more radical surgery to lessen morbidity around eloquent brain areas.

Adolescent↗
PubMed1999

Pericollicular approaches to the rhomboid fossa. Part II. Neurophysiological basis.

OBJECT: The authors describe their technique of electrophysiological mapping to assist pericollicular approaches into the rhomboid fossa. METHODS: Surgical approaches to the rhomboid fossa can be optimized by direct electrical stimulation of superficially located nuclei and fibers. Electrophysiological mapping allows identification of facial nerve fibers, nuclei of the abducent and hypoglossal nerves, motor nucleus of the trigeminal nerve, and the ambiguous nucleus. Stimulation at the surface of the rhomboid fossa performed using the threshold technique allows localization above the area that is located closest to the surface. Simultaneous bilateral electromyographic (EMG) recordings from cranial motor nerves obtained during stimulation document the selectivity of evoked EMG responses. With respect to stimulation parameters and based on morphometric measurements, the site of stimulation can be assumed to be the postsynaptic fibers at the axonal cone. Strict limitation to 10 Hz with a maximum stimulation intensity not exceeding 2 mA can be considered safe. Direct side effects of electrical stimulation were not observed. CONCLUSIONS: Electrical stimulation based on morphometric data obtained on superficial brainstem anatomy defines two safe paramedian supra- and infracollicular approaches to the rhomboid fossa and is particularly helpful in treating intrinsic brainstem lesions that displace normal anatomical structures.

Adult↗
PubMed1998

Decrease of blood pressure by ventrolateral medullary decompression in essential hypertension.

BACKGROUND: About 20% of adults worldwide will develop hypertension. Studies and clinical observations suggest an association between hypertension and pulsatile compression of the ventrolateral medulla oblongata by a looping artery. We investigated whether neurosurgical microvascular decompression substantially decreases blood pressure long-term in patients with severe essential hypertension. METHODS: We included eight patients who had received three or more antihypertensive drugs without adequate control of blood pressure, intolerable side-effects, or both. All patients underwent microvascular decompression at the root-entry zone of cranial nerves IX and X after neurovascular compression of the ventrolateral medulla oblongata was seen on magnetic-resonance angiography. FINDINGS: 3 months after surgery, blood pressure and antihypertensive regimens had decreased substantially in three patients. Four patients who were followed up for more than 1 year became normotensive, but their antihypertensive regimens remained the same as those at 3 months. One patient did not improve. No complications associated with decompression occurred. One patient experienced a transient vocal-cord paresis after the laryngeal part of the vagus nerve was manoeuvered during surgery. INTERPRETATION: We showed a direct causal relation between raised blood pressure and irritation of cranial nerves IX and X. A subgroup of patients with essential hypertension may exist who have secondary forms of hypertension related to neurovascular compression at the ventrolateral medulla and who may be successfully treated with decompression.

Adult↗
PubMed1998

Preservation of hearing in large acoustic neurinomas following removal via suboccipito-lateral approach.

A consecutive series of 61 patients with pre-operative hearing underwent surgical removal of a large acoustic neurinoma via the lateral suboccipital approach between 1984 and 1996. Brain-stem auditory evoked potentials (BAEP) were present in all cases before surgery and all patients underwent intra-operative monitoring of BAEP. The average tumour size including the portion within the meatus acusticus internus was 30, 5 mm (range 20 mm-49 mm). Complete tumour removal was achieved in all but three cases. In 43.1% of patients with complete tumour removal hearing was preserved initially after surgery. Delayed postoperative hearing loss was observed in 11 patients and hearing recovery in 2 patients leading to 27.5% definite hearing preservation. Hearing preservation was achieved in 37% of cases with tumour size between 20 mm-29 mm and in 23.5% of case with tumour size larger than 30 mm. These results indicate that even in large neurinoms hearing preservation should be attempted in all patients with documented pre-operative hearing and BAEP.

Adult↗
PubMed1998

Neuropsychological results of craniopharyngioma surgery in adults: a prospective study.

BACKGROUND: The optimal management of craniopharyngiomas is a topic of ongoing debate. Supporters of limited surgery for craniopharyngiomas claim that more radical approaches are afflicted with adverse neuropsychological sequelae. Since prospective studies on this issue have not yet been performed, we assessed neuropsychological functioning in adults before and after craniopharyngioma surgery. METHODS: Thirteen adults with an age range of 17-76 years (mean, 45 years) were included in the study. Surgery included a transcranial procedure in 10 patients. The bifrontal interhemispheric approach predominated (n = 7). Neuropsychological evaluation was performed before and 3 months after surgery. The test battery was adjusted to evaluate function related to structures in the operative trajectory and at the tumor site. RESULTS: A complete tumor removal was accomplished in eight patients and subtotal removal in three patients. IQ scores for verbal intelligence were in the normal range and not affected by surgery (mean IQ score preoperative: 106.8; postoperative 107.4). In 12 of 13 patients, immediate recall, delayed recall and recognition memory were not impaired after surgery. Postoperative results for abstract thinking were in the normal or above-normal range. Cognitive speed was impaired in three patients preoperatively and in two patients postoperatively. Overall results were significantly better after surgery. Word fluency was not affected by surgery. Quality of life for the category "sleep" was impaired preoperatively, and this improved after surgery. Otherwise, quality of life was normal both before and after surgery. CONCLUSIONS: Neuropsychological performance and quality of life are generally not impaired after surgical removal of craniopharyngiomas. The findings support the attitude that the initial therapy of craniopharyngiomas should be an attempt at total removal.

Adolescent↗
PubMed1998

Overexpression of stimulatory G protein alpha-subunit is a hallmark of most human somatotrophic pituitary tumours and is associated with resistance to GH-releasing hormone.

The heterotrimeric Gs protein-adenylyl cyclase (AC) cascade plays a pivotal role in controlling hormone secretion by endocrine glands. Consequently, deficiency of the alpha-subunit of Gs leads to endocrine hypofunction and hypoplasia in the affected cells whereas AC hyperactivity results from activating point mutations within the Gs-alpha gene. The latter, termed gsp oncogenes, are found primarily in a subset of growth hormone (GH)-secreting human pituitary tumours (somatotrophinomas) and are thus associated with excessive GH secretion. We present here evidence that another type of defect in human somatotrophinomas may be overexpression of the Gs-alpha subunit. Immunohistochemistry using an antibody against recombinant human Gs-alpha revealed high levels of expression in 25 of 39 somatotrophinomas but weak staining in normal human pituitary cells. These results were confirmed by Western blot analysis. Additionally, cholera toxin-mediated ADP-ribosylation in the presence of 32P-labelled NAD+ resulted in an autoradiographic signal intensity which correlated directly with magnitude of immunostaining and amount of antigen shown by Western blot analysis, providing evidence for overexpression of functionally active subunit. Finally, reconstitution assays were applied and directly demonstrated the increased activity of overexpressed Gs-alpha. In vivo, the effect of Gs-alpha on AC activity may be partially counterregulated by high levels of inhibitory G protein that also occurred in these tumours. In culture, GH-releasing hormone (GHRH) had markedly reduced effects on GH secretion by somatotrophinomas exhibiting Gs-alpha overexpression, whereas powerful stimulation occurred in weakly staining tumours. In contrast to these observations with Gs-alpha, immunostaining for the phospholipase C-coupled G11-alpha subunit was relatively weak in all somatotrophinomas studied and synthetic GH-releasing peptide, which acts via a specific G11-coupled receptor, led to powerful and consistent stimulation of GH secretion by different tumours. These results indicate that Gs-alpha overexpression is associated with dysfunction in hormone secretion by some somatotrophinomas.

Adenoma↗
PubMed1998

Presence of GHRH mRNA in human pituitary somatotrophinomas and its relationship to in vitro effect of a GHRH-antagonist on GH secretion and cAMP production.

Several earlier studies have shown that some human pituitary GH-secreting somatotrophinomas are able to synthesise and release hypothalamic GHRH and it has been proposed that a positive autocrine feedback loop involving this tumor-derived GHRH may participate in tumorigenesis. We have used in-vitro cell culture and exploited an antagonist to GHRH, (Ac-Tyr1,D-Arg2)-GHRH (1-29)-amide (GHRH-A), to further investigate whether an autocrine loop involving somatotrophinoma-derived GHRH may exist. In situ hybridization demonstrated presence of GHRH transcripts in 5 of 9 human somatotrophinomas. In culture, GHRH-A failed to inhibit basal release of GH or production of cAMP irrespective of presence or absence of GHRH transcripts. However, GHRH-A was able to completely or partially abolish the stimulatory effects of exogenously added GHRH peptide. Additionally, the average stimulatory effect of exogenous GHRH on in vitro GH secretion by somatotrophinomas possessing GHRH mRNA was identical to that shown by tumors not expressing the GHRH gene. Whilst confirming that many human pituitary somatotrophinomas are able to express the GHRH gene, the failure of GHRH-A to inhibit basal GH secretion argues against the concept of the existence of an autocrine stimulatory loop involving secreted GHRH peptide.

Adenoma↗
PubMed1998

Intraoperative magnetic resonance imaging with the magnetom open scanner: concepts, neurosurgical indications, and procedures: a preliminary report.

OBJECTIVE: Intraoperative magnetic resonance imaging (MRI) is now available with the General Electric MRI system for dedicated intraoperative use. Alternatively, non-dedicated MRI systems require fewer specific adaptations of instrumentation and surgical techniques. In this report, clinical experiences with such a system are presented. METHODS: All patients were surgically treated in a "twin operating theater," consisting of a conventional operating theater with complete neuronavigation equipment (StealthStation and MKM), which allowed surgery with magnetically incompatible instruments, conventional instrumentation and operating microscope, and a radiofrequency-shielded operating room designed for use with an intraoperative MRI scanner (Magnetom Open; Siemens AG, Erlangen, Germany). The Magnetom Open is a 0.2-T MRI scanner with a resistive magnet and specific adaptations that are necessary to integrate the scanner into the surgical environment. The operating theaters lie close together, and patients can be intraoperatively transported from one room to the other. This retrospective analysis includes 55 patients with cerebral lesions, all of whom were surgically treated between March 1996 and September 1997. RESULTS: Thirty-one patients with supratentorial tumors were surgically treated (with navigational guidance) in the conventional operating room, with intraoperative MRI for resection control. For 5 of these 31 patients, intraoperative resection control revealed significant tumor remnants, which led to further tumor resection guided by the information provided by intraoperative MRI. Intraoperative MRI resection control was performed in 18 transsphenoidal operations. In cases with suspected tumor remnants, the surgeon reexplored the sellar region; additional tumor tissue was removed in three of five cases. Follow-up scans were obtained for all patients 1 week and 2 to 3 months after surgery. For 14 of the 18 patients, the images obtained intraoperatively were comparable to those obtained after 2 to 3 months. Intraoperative MRI was also used for six patients undergoing temporal lobe resections for treatment of pharmacoresistant seizures. For these patients, the extent of neocortical and mesial resection was tailored to fit the preoperative findings of morphological and electrophysiological alterations, as well as intraoperative electrocorticographic findings. CONCLUSION: Intraoperative MRI with the Magnetom Open provides considerable additional information to optimize resection during surgical treatment of supratentorial tumors, pituitary adenomas, and epilepsy. The twin operating theater is a true alternative to a dedicated MRI system. Additional efforts are necessary to improve patient transportation time and instrument guidance within the scanner.

Adolescent↗
PubMed1998

Presence of growth hormone secretagogue receptor messenger ribonucleic acid in human pituitary tumors and rat GH3 cells.

A novel G11-protein-coupled receptor specific for synthetic GH-releasing peptides (GHRPs) has recently been cloned and sequenced. Two forms exist, types 1a and 1b, the latter of which is biologically inactive. Using RT-PCR, we looked for the presence in tumorous pituitary cells of messenger ribonucleic acid (mRNA) for this novel GH secretagogue receptor (GHS-R). Both subtypes of GHS-R mRNA were detected in all six human pituitary somatotropinomas removed from patients with acromegaly. In culture, four of the tumors exhibited strong responses to GHRP-2 in terms of both phosphatidylinositol (PI) hydrolysis and GH secretion, but two were resistant. There was no apparent difference in the type 1a and type 1b expression pattern, as judged by RT-PCR, between responsive and nonresponsive tumors. Similarly, the rat pituitary tumor cell line, GH3, was found to express GHS-R mRNA, although these cells also did not respond to GHRPs. RT-PCR failed to detect GHS-R mRNA in eight functionless human pituitary tumors. In contrast, prolactinomas were found to express the receptor and, in culture, significant stimulation of PRL secretion and PI hydrolysis occurred in two of three tumors tested. These results demonstrate that tumorous somatotrophs express the GHS-R gene and that the occasionally observed nonresponsiveness of somatotropinomas to GHRPs is not due to the absence of the biologically active type 1a receptor. Additionally, human pituitary prolactinomas also express GHS-R and are able to respond to GHRPs in terms of PI hydrolysis and PRL secretion. In contrast, GHS-R gene expression does not appear to be associated with human functionless pituitary tumors.

Animals↗
PubMed1998

Comparative genomic hybridization analysis of nonfunctioning pituitary tumors.

Clinically nonfunctioning pituitary adenomas constitute about one third of pituitary neoplasms and are considered monoclonal tumors. The molecular mechanisms of tumorigenesis in these neoplasms are poorly understood, as evidenced by the paucity of reported somatic genetic alterations. Furthermore, the somatic mutations detected to date were primarily ascribed to candidate genes or chromosomal regions: gsp, ras, p53 mutations, and allelic losses of 11q and 13q. To gain insight into which chromosomal regions bear genes involved in nonfunctioning pituitary tumorigenesis, we examined 23 such tumors by comparative genomic hybridization. Four tumors showed no genetic abnormality, and the rest (17 of 23, 74%) exhibited at least one chromosomal region of abnormality. Gains and losses affected all chromosomes (except for chromosome 14). Notably, 8 of 23 tumors (34.7%) displayed sex chromosome and chromosome 18 aberrations (amplifications or deletions). Nonrandom DNA amplification of sub-chromosomal regions on 4q, 5q (5q13-->5q23), 9p (9p21-->9pter), 13q (13q21-->13q32), and 17q were detected in 10-30% of the tumors. Noteworthy, no tumor displayed deletion of 11q, the MEN1 gene locus. These findings suggest that genes localized to previously undescribed chromosomal regions play a role in the tumorigenesis of nonfunctioning pituitary adenomas.

Adenoma↗
PubMed1998

Formation of autocrine loops in human cerebral meningioma tissue by leukemia inhibitor factor, interleukin-6, and oncostatin M: inhibition of meningioma cell growth in vitro by recombinant oncostatin M.

OBJECT: It has been demonstrated that growth of cerebral meningiomas found in humans is controlled by a variety of factors, including growth factors, aminergic agents, neuropeptides, and steroids. To further our knowledge of this process, the authors investigated the presence and function of the cytokines leukemia inhibitory factor (LIF), interleukin-6 (IL-6), and oncostatin M (OSM) on meningioma cell proliferation. METHODS: Active transcription of LIF, IL-6, and OSM, their related receptors (LIF-R, IL-6-R, and gp130), and the consecutive signal-transducing molecules (STAT 1, STAT 3, and STAT 5a) were analyzed in reverse transcriptase-polymerase chain reaction experiments. The presence of endogenous LIF, IL-6, and OSM proteins was demonstrated in the supernatant of cultured meningioma cells using the enzyme-linked immunosorbent assay and Western blot experiments, thus indicating an autocrine signaling pathway for all three cytokines. The biological function of all three cytokines was evaluated by studying their effects on meningioma cell growth. Recombinant LIF and IL-6 showed no significant growth modulating effects; however, recombinant OSM decreased meningioma cell growth by 66%. The antiproliferative potency of OSM was demonstrated by cell count experiments, the [3H]thymidine incorporation assay, and cell cycle analysis. CONCLUSIONS: These in vitro data support the concept that growth of meningioma cells may be modulated by cytokines, and they also indicate that recombinant OSM may be one future candidate for use in the adjuvant treatment of inoperable and recurrent meningiomas.

Acute-Phase Proteins↗
PubMed1998

Severe hyponatremia after transsphenoidal surgery for pituitary adenomas.

Severe hyponatremia has been described after elective surgery with subsequent permanent brain damage. Other authors, however, have noted that morbidity and mortality rates of severe hyponatremia have been greatly overestimated. We retrospectively examined 19 patients (8 male, 11 female) who developed severe hyponatremia (100 to 124 mmol/liter) after transsphenoidal surgery for pituitary adenomas. Eight patients had hormonally inactive adenomas, 5 ACTH-secreting adenomas, 2 GH-secreting adenomas and 4 prolactin-secreting adenomas. The mean age of the patients was 47.5 years, with a range from 16 to 71 years. The mean preoperative serum sodium level was 137.8 mmol/liter. The timing of hyponatremia showed two different patterns. Five patients developed early postoperative hyponatremia (mean 114.0 mmol/liter +/- 4.85) and 14 patients showed the lowest mean serum level one week after surgery (118.1 mmol/liter +/- 6.86). Patients with early hyponatremia had fewer and less severe symptoms than patients with delayed hyponatremia. None of the patients developed seizures or a demyelination syndrome. Despite severe degree of hyponatremia for most of our patients treatment with water restriction and oral sodium supplementation was sufficient.

Adenoma↗
PubMed1997

Open surgery of giant paraclinoid aneurysms improved by intraoperative angiography and endovascular retrograde suction decompression.

In three consecutive cases of giant left sided paraclinoid aneurysms we employed an endovascular retrograde suction decompression technique in combination with intra-operative angiography. A double-lumen balloon catheter was placed in the left internal carotid artery by the transfemoral route. After balloon inflation and placement of a temporary clip distal to the aneurysm blood was aspirated and the aneurysm collapsed. Thus further dissection of the aneurysm could easily be achieved and clips could be placed. Afterwards real-time digital subtraction angiography was performed. Intra-operative angiography led to clip repositioning in all cases either due to a clip induced stenosis of the parent vessel, or because of incomplete aneurysm obliteration. Afterwards successful clipping could be confirmed in all cases. Outcome was excellent in one case, good in the other. The third case, extremely complicated by an accompanying craniopharyngioma, showed a satisfactory outcome, but presented new neurological deficits.

Cerebral Angiography↗