Deep brain stimulation (DBS) of the posterior hypothalamus was found to be effective in the treatment of drug-resistant chronic cluster headache. We report the results of a multicentre case series of six patients with chronic cluster headache in whom a DBS in the posterior hypothalamus was performed. Electrodes were implanted stereotactically in the ipsilateral posterior hypothalamus according to published coordinates 2 mm lateral, 3 mm posterior and 5 mm inferior referenced to the mid-AC-PC line. Microelectrode recordings at the target revealed single unit activity with a mean discharge rate of 17 Hz (range 13-35 Hz, n = 4). Out of six patients, four showed a profound decrease of their attack frequency and pain intensity on the visual analogue scale during the first 6 months. Of these, one patient was attack free for 6 months under neurostimulation before returning to the baseline which led to abortion of the DBS. Two patients had experienced only a marginal, non-significant decrease within the first weeks under neurostimulation before returning to their former attack frequency. After a mean follow-up of 17 months, three patients are almost completely attack free, whereas three patients can be considered as treatment failures. The stimulation was well tolerated and stimulation-related side-effects were not observed on long term. DBS of the posterior inferior hypothalamus is an effective therapeutic option in a subset of patients. Future controlled multicentre trials will need to confirm this open-label experience and should help to better define predictive factors for non-responders.

The combination of neuronavigation with cortical stimulation and repetitive neurological and language examinations allows a more radical resection of tumors in eloquent brain areas, otherwise considered as inoperable.

Deep brain stimulation of the posterior inferior hypothalamus is an experimental procedure and should be restricted to selected therapy-refractory patients and should be performed in centers experienced in patient selection and performance of DBS as well as postoperative pain treatment. A prospective multi-centre study is necessary to evaluate its effectiveness.

The authors report a rare case of metastatic atypical meningioma WHO grade II involving the dorso-lateral region of the cervical spine and causing spinal cord compression in a 76-year-old man. The patient was treated surgically in June 1998 for an atypical parasagittal meningioma in the right frontal lobe. Local recurrence with extension to the left hemisphere required surgical treatment in January 2000, and in December 2000 recurrence caused paraplegia of the lower extremities and paresis of the left arm. A 3 (rd) operation was carried out in January 2001, followed by radiotherapy with a total dose of 45 Gy. The patient presented again in March 2003 because of pain in the neck and a progredient new paresis and paresthesia of the right arm. Computed tomogram of the cervical spine showed a large tumor with compression of the spinal cord. MRI was not possible due to a pacemaker which had been implanted in the meantime. Surgical subtotal removal of the tumor via hemilaminectomy of the 3 (rd) and 4 (th) cervical vertebrae was performed. After decompression of the cervical spine the paresis of the right arm improved, the paraplegia of the legs and the left arm, existing since December 2000, remained unchanged. Histological findings of the cranial lesions and the metastatic lesion had a similar appearance and were compatible with atypical meningioma (WHO grade II).

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