Operative or endovascular treatment of ruptured intracranial vertebral artery aneurysms?

Our purpose was to evaluate the surgical and endovascular treatment outcomes of ruptured intracranial vertebral artery aneurysms (RIVAA). The outcomes of 44 patients with RIVAA treated between 1983 and 1998 surgically (26), endovascularly (20) or both (2) were evaluated. The aneurysms were clipped in 24 patients, and clipped and wrapped in two. We treated 20 by the endovascular approach, 12 with Guglielmi detachable coils (GDC), and eight by parent-vessel occlusion using detachable balloons. Three patients had endovascular treatment after a failed or inadequate surgical attempt. Posttreatment follow-up was 17-183 months (mean 101 months) for surgically treated patients. For the GDC-treated group angiographic follow-up was carried at 8-49 months (mean 19 months). The condition of seven (27 %) of the surgically treated patients worsened due to procedure-related complications, compared with 10% in the endovascular treatment group. Of the patients initially presenting with Hunt and Hess grade IV or V, three of five (60%) died who were treated surgically and two of eight (25%) who were treated endovascularly. A good outcome was achieved in 17 surgically treated patients (85% of the survivors) and in 16 of the endovascular group (89% of the survivors). This present "same-site" report on treatment of a specific abnormality, RIVAA, treated surgically or by an endovascular approach indicates that especially in poorer Hunt and Hess grade patients, the latter may offer a clinical outcome as good as that of surgery, although long-term efficacy of GDC treatment is still to be determined.

Surgery, tamoxifen, carboplatin, and radiotherapy in the treatment of newly diagnosed glioblastoma patients

A historically controlled phase II study was undertaken to investigate the efficacy and toxicity of a postoperative treatment consisting of high-dose continuous tamoxifen, carboplatin and radiotherapy in patients with newly diagnosed glioblastoma. Between 1995 and 1998, 50 patients with newly diagnosed glioblastomas underwent surgery and were subsequently treated with 200 mg day(-1) tamoxifen continuously, 3 cycles of carboplatin (300 mg m(-2)), and radiotherapy. Survival data for a historical control group were calculated from respective prognostic indices and were obtained from studies with comparable patient populations treated with operation and radiotherapy only. In our study, the median time to tumor progression was 30 weeks and the median survival time (MST) 55 weeks (95% confidence interval: 46-63 weeks). The MST of the control group (48 weeks) showed to be within this interval. In addition to already known prognostic factors in malignant gliomas (age, Karnofsky performance score, extent of tumor resection), the gender (females lived longer than males, p = 0.0025) showed to influence survival. Serious side effects (thrombosis, pulmonary embolism) occurred in 6 patients. A high incidence of multifocal tumor recurrences (33%), which might be related to study-treatment, was observed. In conclusion, the combined therapy failed to demonstrate a higher efficacy than standard treatment for glioblastoma patients.

Surgical management of intramedullary hemangioblastoma of the spinal cord

This is a study on 19 patients, who underwent complete excision of an intramedullary hemangioblastoma of the spinal cord during the period 1984-1997. The study was conducted to evaluate their functional outcome. Some peculiarities of their clinical presentation and surgical treatment are discussed as well. There were 12 males and 7 females whose age ranged from 16 to 69 years. Five of 6 patients were affected by Lindau's disease had multiple intramedullary tumors. The length of their history averaged 22.6 months. While pain was the most common complaint at presentation, 12 out of 19 patients had progressive sensorimotor deficits. A total of 22 operation was performed. One patient underwent resection of a minute tumor residue a few months after the first operation. In 2 patients with multiple tumors a second tumor, which became clinically relevant, was resected 17 and 36 months after the first operation. There was no mortality. One patients developed a wound infection which required secondary closure. The functional status of the patients registered at discharge was worse in 22.7%, unchanged in 59.1%, and improved in 18.2% of the patients. At follow-up (6-142 months), the status of 9.1% of the patients was still worse, in 50% was unchanged and in 40.9% better than the preoperative one. All but one patients had complete postoperative pain relief. The data support the concept that radical excision of intramedullary hemangioblastomas can be achieved at low levels of surgical mortality and morbidity. Symptomatic patients should undergo surgery before they develop extensive sensorimotor deficits. In patients with multiple lesions, tumors distant from the symptomatic one should not be tackled.

Suprasellar meningiomas--neurological and visual outcome at long-term follow-up in a homogeneous series of patients treated microsurgically

Most of the previously published surgical series of suprasellar meningiomas have two disadvantages: (1) patients involved were treated within a relatively long time period, making analysis more difficult, (2) radiographic long term follow-up examinations with either CT- or MRI-scans were not performed. Both disadvantages were overcome in our retrospective clinical study, consisting of 50 consecutive patients with suprasellar meningiomas treated between 1982 and 1991. Radiological, ophthalmological, and neurological investigations were performed preoperatively, postoperatively and at long term follow-up (mean: 5.7 years). A radiologically confirmed radical tumour removal could be achieved in 84% of patients. Both, the peri-operative mortality (2%) and serious operative morbidity (6%) were low. However, 12% of patients developed late onset epilepsy. At long term follow-up, visual function was improved in 67%, unchanged in 9% and worsened in 24%. In more than 50% of patients the vision showed recovery over a longer time period than the first 10 days after operation. Radiographic control examinations revealed tumour recurrences in 2 patients (both asymptomatic) and progress of residual tumour in 5 patients (2 symptomatic, 3 asymptomatic). Since introduction of modern neurosurgery, a clear improvement in the surgical treatment of suprasellar meningiomas can be observed. However, the still long delay in diagnosing these tumours correctly prevents a further improvement of the ophthalmological results at long-term follow-up. Due to a relatively high rate of late onset epilepsy, anticonvulsive prophylaxis for 6 months seems to be justified. Regarding present preoperative diagnostic measures, ia-DSA seems only be indicated in patients with CT/MRI-scans, suspicious for tumourous narrowing or invasion of major cerebral arteries. In addition, we recommend radiographic control examinations at regular time intervals to confirm radical tumour removal and to detect the "ideal" point of time for renewed treatment.

Preoperative functional magnetic resonance imaging (fMRI) of the motor system in patients with tumours in the parietal lobe

Intracranial lesions may compromise structures critical for motor performance, and mapping of the cortex, especially of the motor hand area, is important to reduce postoperative morbidity. We investigated nine patients with parietal lobe tumours and used functional MRI sensitized to changes in blood oxygenation to define the different motor areas, especially the primary sensorimotor cortex, in relation to the localization of the tumour. Activation was determined by pixel-by-pixel correlation of the signal intensity time course with a reference waveform equivalent to the stimulus protocol. All subjects showed significant activation of the primary sensorimotor cortex while performing a finger opposition task with the affected and unaffected side. In five patients the finger opposition task additionally activated the ipsilateral sensorimotor cortex and the supplementary motor area (SMA). Extension and flexion of the foot, additionally performed in two patients, also activated the sensorimotor cortex, in one case within the perifocal oedema of the tumour. Tumour localization near the central sulcus induced displacement of the sensorimotor cortex as compared to the unaffected side in all patients with a relevant mass effect. The results of our study demonstrate that functional MRI at 1.5 T with a clinically used tomograph can reproducibly localize critical brain regions in patients with intracranial lesions.

Tissue culture of human neurocytomas induces the expression of glial fibrilary acidic protein

Cell cultures were established from three human neurocytoma specimens (primary and recurrent). The phenotypic evolution was analyzed by immunocytology in different culture conditions in the presence and absence of serum including the addition of epidermal growth factor, rat caudate extract, retinoic acid, and N-acetyl cystein. The cells were grown on glass cover slides or an extracellular matrix (ECM) from bovine corneal endothelial cells. Immunostainings were performed after overnight incubation and were repeated after 5 and 10 days of culture. The cultures were compared to an oligoastrocytoma also arising at the foramen of Monro and an ependymoma of the frontal lateral ventricle, two tumors supposedly originating from the same tissue matrix as the neurocytoma. After overnight incubation, 90% of the neurocytoma cells were positive for A2B5 and synaptophysin. GFAP reactivity appeared in the periphery of cell processes in less than 1% of the cells. The staining patterns and morphology were nearly identical under the different culture conditions. After 5 days, almost all cells were strongly positive for GFAP, while the number of cells remaining positive for synaptophysin and A2B5 was unchanged from the earlier time point. Again, there were no fundamental differences between the incubation conditions. At this point, cultures maintained on ECM were compared to their counterparts on untreated glass cover slides with identical staining results, although many fewer cells had attached. An identical immuno-reactive pattern was found on day 10. In contrast to the neurocytoma cultures, there was an immediate strong GFAP signal in both the mixed glioma and the ependymoma. A2B5 was also positive, but synaptophysin was absent. Because the neurocytoma specimens were synaptophysin positive but GFAP negative by immunohistochemistry, it is concluded that neurocytomas may represent a human neuronoglial precursor tumor that switches its phenotype in culture to astroglial differentiation despite very diverse culture conditions.

[Suprasellar meningioma. A disease still frequently diagnosed too late]

BACKGROUND AND OBJECTIVE

Suprasellar meningioma continues to be diagnosed very late after the onset of first eye symptoms. This study was aimed at demonstrating the effect of delay on the long-term visual loss.

PATIENTS AND METHODS

In the course of a retrospective study all 53 consecutive patients operated on for suprasellar meningioma from 1982 to 1991 were contacted (47 women, 6 men; average age 49.5 years) 46 of the 49 surviving consented to the follow-up investigation. The extent of preoperative visual loss, tumour size, presence of optic nerve atrophy and duration of visual loss, data that provide an indirect measure of how soon the correct diagnosis was made, were analysed with regard to their effect on long-term ophthalmological results.

RESULTS

The mean period elapsing from onset of first visual symptoms to the definitive diagnosis of suprasellar meningioma was 22.3 months. The data showed that the long-term results were the worse the later the diagnosis was made.

CONCLUSIONS

The commonly very late diagnosis of suprasellar meningioma as cause of visual loss is an international problem and is presumably due to the low incidence of the tumour (1-2 cases per 1 mill. population per year). If long-term results are to be improved, primary care doctors must be made aware of the differential diagnosis of visual loss caused by pressure from a tumour.

Treatment and long-term outcome of pineal nongerminomatous germ cell tumors

In 1994 we reported on a small series of 3 children with malignant, marker-positive pineal nongerminomatous germ cell tumors treated with a 'sandwich' protocol. Here, we report on the long-term survival of these children. Preoperative chemotherapy consisted of two courses of bleomycin, etoposide, and cisplatin. En bloc resection of the tumors via the supracerebellar, infratentorial route was performed immediately after decline of tumor marker levels. Postoperatively, two courses of vinblastine, ifosfamide, and cisplatin were applied, followed by craniospinal irradiation. The patients showed no major neurological deficits and no evidence (neuroradiologically or with regard to tumor marker levels) of recurrence of disease after 66, 71, and 78 months, respectively. We propose this regimen for children with tumors of the pineal region in whom the tumor markers are positive. It should be started without histological classification of the tumor to avoid possible spillage of malignant tumor cells to the cerebrospinal fluid.

[Asymptomatic cerebral aneurysms--surgical and endovascular therapy options]

Aneurysmal subarachnoid hemorrhage carries a risk of 50% mortality. Therefore it is recommended to also treat asymptomatic, previously unruptured aneurysms. Deciding whether to treat or to observe depends on the consideration of risk of hemorrhage and the surgical risk. Such decision could be facilitated if predisposing factors affecting the outcome were known. 15 Patients with 19 unruptured aneurysms managed in a period when both, surgical and endovascular treatment options were available, were selected from a group of 47 asymptomatic patients documented since 1984. The patients were either operated (n = 9) or were treated by endovascular occlusion with GDC coils (n = 6). In most cases, a long history of headaches eventually lead to a CT-scan or MRI in which a suspicious abnormality was found. Upon subsequent angiography, 8 middle cerebral, 6 carotid, 3 basilar and 1 pericallosal, and ophthalmic artery aneurysm(s), respectively, were found. The aneurysms varied from 4 to 30 mm in diameter. The patients were followed between 9 months and 2.5 years. Treatment results in this small series were independent from size, location, age or sex of the patient. The initial, mostly unrelated symptoms persisted after treatment in most cases. The morbidity according to GOS in this small series (3 out of 19 patients deteriorated) is not representative of the complete series where morbidity and mortality was 5.4% and 1.2% respectively). In agreement with the literature reviewed herein, we recommend surgical treatment of previously unruptured aneurysms, especially when the patients are below 60 years of age. In patients with posterior circulation aneurysms, endovascular coil occlusion is a valid alternative, especially in older patients with concurrent medical problems.

Intracranial germ-cell tumours--treatment results and residuals

There is only sparse information about the development of children after successful treatment for intracranial germ-cell tumours. Between January 1981 and June 1992, 26 children with intracranial germ-cell tumours were treated in the University Hospital Hamburg-Eppendorf. We report on treatment results, long standing residuals and the "quality of life" of these patients. The long-term event-free survival was 88% for the germinomas and 43% for the malignant teratomas. Of the patients 58% had no relevant functional neurological deficits and 37% had mild impairment. Only 1 patient with metastatic disease was severely handicapped. Six patients showed neuro-endocrine dysfunction. All of them had suprasellar/hypothalamic lesions and all received successful substitution therapy. As to neuropsychological functions, 53% of the patients had no or only mild disturbances. The most affected function was speed of information processing. Of the children 69% were able to proceed with their education at the same level as before therapy. The overall self-assessment revealed good results in 75% of the patients.

CONCLUSION

After surgical removal and radiation therapy long-term survival of intracranial germinomas amounts to 88%. Despite craniospinal axis radiation severe residuals are rare and a good quality of life is common. In malignant teratomas treatment regimens including chemotherapy are much less successful.

Central neurocytoma: clinical, immunohistologic, and biologic findings of a human neuroglial progenitor tumor

BACKGROUND

Central neurocytomas are rare brain tumors recognized by their typical radiologic and histologic features. In general, a good prognosis is achieved by total removal. The histogenesis is still under debate, but a neuronal origin is widely assumed.

METHODS

This study presents the clinical and immunohistologic findings of five patients and the results of cell culture experiments of two patients with central neurocytoma treated surgically between 1983 and 1993.

RESULTS

The patient age at diagnosis ranged from 21 to 30 years (mean, 25 years). The male-to-female ration was 1:4. Raised intracranial pressure due to hydrocephalus was the main cause of the clinical manifestations. Total resection was achieved in two cases. Four patients received radiotherapy. One patient suffered a recurrence 1 year after surgery, requiring a second resection and radiotherapy. Follow-up studies took place between 1 and 10.5 years (mean, 7.1 years). To date, all patients are free of their tumors. Two patients suffered from permanent memory disturbances after surgery. Immunohistochemistry confirmed the neuronal nature of the tumors. Cell-culture studies, which have been carried out for the first time, demonstrated concomitant expression of neuronal (synaptophysin) and glial (GFAP) markers.

CONCLUSION

Total removal is the therapy of choice. In tumor recurrence or limited surgery (e.g. due to severe affliction of the fornical structures), radiotherapy has shown to be efficacious. The cell-culture experiments give new insight on the histogenesis of central neurocytoma, indicating that the tumor arises from an undifferentiated precursor cell with the capacity of bipotential neuroglial differentiation.

Malignant chiasmal glioma: a rare cause of rapid visual loss

The clinical, neuroradiological, and histological findings of an adult patient suffering from malignant optic glioma is reported. Rapid visual deterioration was misdiagnosed for several months until biopsy confirmed the tumor. The patient died despite radiation therapy nine months after first symptoms. Our presentation will focus on the problems of diagnosing and establishing therapeutic procedures in this rare malignant neoplasm.

Human neurocytoma cells in culture show characteristics of astroglial differentiation

Cultured human neurocytoma cells from two neurosurgical patients were analysed for their immunocytochemical staining patterns and growth characteristics. In both cases, the cells stained positive for glial acidic fibrillary protein (GFAP) within one day of tissue culture in medium, with and without fetal calf serum, whereas the histological tumor specimens were negative. Both cases contained cells concomitantly expressing GFAP and synaptophysin (SNP) in the primary cultures. Epidermal growth factor (EGF) was mitogenic for the cultured cells but not platelet derived growth factor alpha (PDGF AA) or nerve growth factor (NGF). It is concluded that the human neurocytomas may represent neoplasms of a pluripotent neuroglial cell which can provide an interesting model to study the determinants for human glial/neuronal differentiation in vitro.

Surgical management of intramedullary spinal cord tumors: functional outcome and sources of morbidity

We are reporting the functional outcome of 69 of 86 patients affected by intramedullary spinal cord tumors who underwent surgery at our department during the period of 1984 to 1992. The results on 17 patients affected by hemangioblastomas and cavernomas were excluded from this study and will be published separately. Twenty-eight patients had astrocytic processes; 34 had ependymoma; 4 had lipoma; 2 had neurofibroma; and 1 had oligodendroglioma. The overall rate of "radically" resected tumors was 55.1%, as opposed to 17.4% "quasiradically," and 27.5% of "partially" resected processes. There was one postoperative death. Five other patients, affected by anaplastic astrocytomas, died because of tumor progress within 16 months from the operation. A postoperative functional assessment showed that the function of the upper and lower extremities had deteriorated in 65.4 and 55.1% of the patients; a respective functional deterioration by 1 degree of the scale of Cooper and Epstein was registered in 88.8 and 86.8% of the patients. The patients who recovered improved within a period of 6 to 18 months, whereas the function of the dorsal columns was impaired the longest. At follow-up (mean, 54 mo; range, 8-107 mo), the functional recovery (as compared with the preoperative status) was as follows: upper extremity, 17.1% of the patients were improved, 55.5% were unchanged, and 31.5% were worse (89.4% by 1 degree); lower extremity, 22.4% of the patients were improved, 51.5% were unchanged, and 29.4% were worse (most by 1 degree). Surgery on tumors of the cervicothoracic and upper thoracic region carried a relatively higher morbidity in this series.(ABSTRACT TRUNCATED AT 250 WORDS)

Hypothalamic hamartomas: with special reference to gelastic epilepsy and surgery

This study presents six patients with hypothalamic hamartomas diagnosed on the basis of magnetic resonance imaging. Histological confirmation was performed in three patients who underwent surgery. Immunohistological assays were used to determine the neurosecretory pattern. Four patients presented with epilepsy, including gelastic seizures. Other symptoms included behavioral abnormalities in four patients and precocious puberty and visual impairment in two patients. One patient presented associated developmental defects. Good results without morbidity were achieved with surgical resectioning in two patients with large hamartomas associated with behavioral abnormalities and gelastic epilepsy that was unresponsive to conventional medical treatment and in one patient with visual impairment. We propose a classification of the hypothalamic hamartomas based on topographical and clinical data obtained from 36 selected cases in the literature and six of our own cases. This classification should help to classify the various treatment methods and the surgical risks into four subgroups (Types la, lb, lla, and llb). We conclude that the surgical approach is a realistic alternative in certain cases, including large and broad-based Type llb hamartomas associated with gelastic epilepsy and behavioral disorders.

Treatment of cerebral arteriovenous malformations by neuroradiological intervention and surgical resection

We present the results of a series of 105 patients with cerebral arteriovenous malformations (AVMs) who were treated by a combined protocol including endovascular occlusive measures and open surgical resection. 25 patients were treated only by surgical intervention, 72 patients underwent preoperative endovascular embolization and 8 patients were treated only by embolization, seven of which were only treated for palliation. After superselective angiography the vascular territories suitable for endovascular or microsurgical approach were defined, and in most cases these territories were complementary to each other. In 56 cases, only one embolization was necessary and due to an advantageous co-localization of the departments the whole combined endovascular/neurosurgical procedure was done in one anesthesia. If several endovascular sessions were necessary (16 patients), the resection was mostly carried out immediately after the last neuroradiological session in the same anesthesia with total time of such combined procedure now averaging about 7 hours. According to the proposed grading system by Spetzler we treated 25 grade 1, 24 grade 2, 40 grade 3, 11 grade 4, and 5 grade 5 lesions. The overall success rate defined as complete resection without additional permanent neurological deficit was 89.6% (87 out of 97 surgical cases). The benefits of such combined approach to cerebral AVMs become apparent in shortened and safer surgical procedures as well as in a low complication rate.

Cranio-cervical decompression for Chiari I malformation. A retrospective evaluation of functional outcome with particular attention to the motor deficits

We report a series of 26 patients affected by a Chiari I malformation treated at our department between 1987 and 1993. All patients underwent pre- and postoperative evaluation by magnetic resonance imaging (MRI). Sequential perioperative motor evoked potential (MEP) recordings were performed in 8 patients. The preoperative symptoms can be divided into four subgroups: cephalgias (84.6%), cranial nerve deficits (69.2%), motor deficits (76.9%), sensory deficits (73%). Twenty-five out of 26 patients underwent craniovertebral decompression, 1 a transoral anterior decompression. One patient died 2 months after surgery because of progressive pulmonary failure. We registered following postoperative complications transient hypoglossal palsy (1 case), vertigo (2 cases), meningitis (1 case), minor CSF leaks (3 cases). Cephalgias subsided in 17 and improved in 4 out of 22 patients. Cranial nerve deficits improved in 8 and were stabilized in 7 out of 18 patients. A limited recovery of trigeminal function was possibly due to nuclear lesions. Five patients whose vestibular disturbances were not relieved by surgery were put on a course of carbazepine. Vertigo resolved in one case and in two others improved. While hypesthesia improved after decompression, the other sensory deficits were stabilized in 5% of the patients. Spasticity improved in 12 out of 18 patients, but weakness only in 7 out of 17 patients. Motor disturbances were always detected by MEP-recording. MEP-characteristics were not specific, resembling those of patients with other intra-, extramedullary myelopathies. Functional recovery was not matched by an improvement of the MEP parameters. MEP may be used as tool for surveillance of patients whose clinical findings are not progressive and are not at first surgical candidates.

Treatment of nongerminomatous germ-cell tumors of the pineal region

Germ-cell tumors can be subdivided into germinoma, embryonal carcinoma, choriocarcinoma, endodermal sinus tumor (yolk-sac tumor), and teratoma. They are also distinguished by their production of secreted markers such as alpha-fetoprotein produced in endodermal sinus tumors and embryonal carcinoma or beta-human chorionic gonadotropin, produced by choriocarcinoma and embryonal carcinoma. Germinoma and teratoma produce none of the markers. Because it has been proposed that teratomas may differentiate from multipotent stem cells contained in embryonal carcinoma and are thus lineage related, the presence of markers indicates the presence of a nongerminomatous germ-cell tumor. Nongerminomatous germ-cell tumors are an invariably fatal subgroup within the pediatric pineal region germ-cell tumors. There is no effective, established therapeutic regimen. We report the treatment regimen for three children diagnosed with this highly aggressive tumor entity. The children were first given a course of chemotherapy with bleomycin, etoposide, and cisplatin. This resulted in the normalization of markers and the shrinkage of tumors. These were then removed by the infratentorial supracerebellar approach. Removal was followed by a second course of chemotherapy with vinblastine, ifosfamide, and cisplatin; after which the children underwent radiotherapy. All three children are well and without evidence of residual or recurrent disease 20, 30, and 32 months after surgery, respectively. We propose this therapy regimen for children in whom the markers are positive.

p53 protein accumulation and gene mutations in human glioma cell lines

Mutations in, and aberrant expression of, the p53 tumor suppressor gene were assessed in 17 cell lines derived from human malignant brain tumors (glioblastoma multiforme). Exons 5 through 8 were screened by single strand conformational polymorphism analysis (SSCP), followed by direct DNA sequencing. Mutations were found in 6 of 17 glioma cell lines, i.e., at a frequency similar to that found in primary malignant gliomas. Loss of the wild type allele was observed in 4 of the mutated cell lines. Two cell lines had the same mutation (CGG-->TGG; Arg-->Trp) in codon 248. Five of 6 mutations were transitions, 4 of which occurred at CpG dinucleotides. In one cell line a 10-bp deletion at the intron 4/exon 5 junction was found. Five of 6 glioma cell lines contained a mutation identical to that in the respective primary tumor despite prolonged in vitro culture (140-221 passages). Thus, the acquisition of p53 mutations during culture appears to be infrequent. Two cell lines derived from heterozygous tumors maintained the wild type p53 allele during long term culture. p53 protein levels were assessed by immunofluorescence cytochemistry and immunoprecipitation followed by Western blot analysis and revealed elevated levels of the p53 protein, although to a variable extent, in all cell lines with p53 mutations. A marked p53 protein accumulation was also observed in two cell lines lacking p53 mutations in exons 5 through 8, indicating that a prolonged half life of the gene product is not solely dependent on an aberrant coding sequence. The remaining cell lines had either low levels or no detectable p53 protein; one of the latter contained a gross rearrangement of the p53 gene. Our results suggest that with respect to p53 gene status, glioma cell lines usually resemble the original tumors and may, therefore, be suitable for studying the biological changes associated with p53 mutations in glial tumors.

A joint protocol for the neurosurgical and neuroradiologic treatment of cerebral arteriovenous malformations: indications, technique, and results in 76 cases

We report on a group of 76 patients who had been treated during a period in which preoperative embolization using interventional neuroradiologic technique was standard procedure. During this time, 20 consecutive patients were operated on without embolization, eight patients were treated with embolization only, and 48 patients were operated on after embolization. In 35 cases surgery immediately followed the last embolization procedure. All arteriovenous malformations (AVMs) were classified and the outcome analyzed according to Spetzler [J Neurosurg 1986; 65: 476-83]. Those lesions treated with a combination of embolization and surgery had higher Spetzler grading than those that had been operated without previous embolization. The overall recovery rate was 82.9%. In 7.9% of the cases the AVMs were not totally extirpated. The overall complication rate was 9.2%. It is concluded that preoperative embolization facilitates surgery and reduces the risk of severe morbidity and mortality, especially in high-grade lesions. In addition to the clinical results, the application and usefulness of Ethibloc as an embolizing agent is reported.

[Improved prognosis of intracranial germ cell tumors by intensified therapy: results of the MAKEI 89 therapy protocol]

Germ cell tumors of the central nervous system are histological identical to the extracranial tumor sites. According to the localisation germ cell tumors of the CNS are different in symptoms, diagnostic approaches, kind and location of metastases and stratification of therapy. Since 1986 patients with intracranial germ cell tumors are registered in the ongoing study for non-testicular germ cell tumors (MAKEI) of the German Society of Pediatric Oncology and Hematology, and are treated in accordance to therapy guidelines for extracranial sites. In MAKEI 89 therapy strategy was revised with a reduction of radiotherapy and an increased cumulative cisplatinum dose from 200 mg/m2 to 400 mg/m2. Patients with germinoma receive after histologic diagnosis radiotherapy consisting of 30 Gy craniospinal irradiation and 15 Gy tumorboost. Malignant non-germinoma receive after diagnosis by tumor marker in CSF and/or serum 2 courses bleomycin 15 mg/m2 day 1-3, Etoposide 150 mg/m2 day 1 + 2 and cisplatinum 20 mg/m2 days 4-8 (BEP), continued by 2 courses Vinblastine 3 mg/m2 day 1 + 2, Ifosfamide 1500 mg/m2 days 1-5 and cisplatinum 20 mg/m2 days 1-5 (VIP), followed by 30 Gy craniospinal irradiation and 20 Gy tumor boost. In teratoma first line therapy is complete resection. In incomplete resected cases adjuvant chemotherapy according to histological grading is administered. Until 31st January, 1993 101 patients (pts) were registered, containing 69 protocol pts. Diagnosis in protocol pts was teratoma in 8 cases, 2 pts died postnatal because of extended disease, 2/8 pts relapsed, but were salvaged by chemotherapy. 40 pts offered germinomas.(ABSTRACT TRUNCATED AT 250 WORDS)

Thiamine-deficient encephalopathy in association with aneurysmal subarachnoid hemorrhage: a case report

An alcoholic man who was admitted with an acute onset of neck pain and confusion was diagnosed as suffering from a subarachnoid hemorrhage after rupture of an anterior communicating artery aneurysm. Additionally, he showed a bilateral 6th nerve palsy of variable extent. The postoperative course was complicated by pulmonary edema and adult respiratory distress syndrome. He died on Day 28 after admission. At autopsy, surprisingly, the concomitant diagnosis of acute thiamine-deficient encephalopathy was made. Thiamine had been given only in minimal amounts during hospitalization. We describe the striking clinicopathological features of this previously undocumented case and consider the relationship between the two central nervous diseases.

Autoradiographic demonstration of in vivo 125I-growth hormone-releasing hormone (GHRH) binding by human GH-secreting pituitary adenomas transplanted on athymic nude mice

This study was designed for the purpose of investigating a method for in vivo tumor labelling of human GH (hGH) secreting pituitary adenomas. Pituitary adenoma tissue removed from four acromegalic patients was transplanted into 62 athymic nude mice. After positive GHRH stimulation tests 125I-GHRH(1-44) NH2 was injected intravenously (i.v.) in ten nude mice. 10 min after 125I-GHRH injection, the nude mice were sacrificed, the transplants excised and prepared for light microscopical autoradiography. The mouse pituitary and skeletal muscle specimens served as controls. After the i.v. injection of 125I-GHRH we observed a marked accumulation of silver grains within the adenoma tissue indicating tumor labelling. This study is a first step in investigating a new method for labelling small residues of hGH secreting pituitary adenomas intraoperatively.

Treatment of tumours of the pineal region and posterior part of the third ventricle

The evaluation of tumours located in the posterior part of the third ventricle or pineal region is achieved best by magnet resonance imaging (MRI). It shows the exact localization and extent, the involvement of neighbouring structures like thalamus or quadrigeminal plate and the displacement of the large veins, the internal cerebral veins, the vein of Galen and the veins of Rosenthal. If only CT is available, angiography should be performed prior to operation to identify the course of the veins. In children with a pineal region tumour the "tumour markers" AFP and beta-HCG should be determined before operation. We approach the rare tumours entirely located within the posterior part of the third ventricle by the posterior interhemispheric transcallosal route with the patient in prone position with the head elevated. The same approach is used for pineal region tumours extending above the internal cerebral veins. Tumours arising from the posterior thalamus extending into the thalamus and ventricle as well, are better approached by the posterior transcortical transventricular route since the lateral view is rather limited by the midline approach. The most frequent tumours in the pineal region are approached if they are located below the internal veins by the infratentorial, supracerebellar route in the sitting position. A total of 60 cases are evaluated. If AFP and/or beta-HCG are positive a highly malignant nongerminomatous germ-cell tumour must be suspected. We recommend initial chemotherapy with a combination of Vinblastine, Ifosfamide and Cis-platin without biopsy to avoid tumour seeding. After the "markers" are normalized operative removal of the residual tumour and radiotherapy should be carried out. In a series of 13 children operated on for pineal region tumours a rigid neuropsychological and endocrine evaluation was performed with encouraging results. During the last 10 years we have performed 49 open operations and 11 stereotactic biopsies. 40% of the patients were children under the age of 18. 40% of the tumours in childhood and 60% in adults were benign. In childhood 24% were germinomas and 20% non-germinomatous germ cell tumours.

Receptors for platelet derived growth factor in human glioma cell lines and influence of suramin on cell proliferation

A panel of 11 established human glioma cell lines was used to evaluate PDGF receptor binding using radioiodinated biosynthetic PDGF-AA and PDGF-AB as primary ligands. It was found that PDGF-receptor-binding was qualitatively heterogeneous. The affinities for PDGF-AA as well as PDGF-AB binding were within a close range of 0.13-0.33 nM and 0.16-1.1 nM, respectively. The number of binding sites per cell ranged between 56.000 and 250.000 for PDGF-AA and 72.000 to 300.000 for PDGF-AB. Two lines had only background levels of PDGF-AA binding. PDGF-AB binding was the dominant binding component in all but one cell line. In seven cell lines there were two binding components upon saturation analysis consisting of a high affinity component and a non-saturable low affinity component. PDGF and PDGF-receptors are suspected to be part of an autocrine loop in gliomas. Therefore, the effect of suramin on cell proliferation in serumfree cultures was tested in the same cell lines using doses of 25,200 or 500 micrograms/ml. It was found that the response to suramin was variable and that two cell lines still reached 2.8 fold and 4.5 fold their initial cell density even in the presence of 500 micrograms/ml whereas all other cells were completely arrested. Analyzing the response to 200 micrograms/ml it became evident, that the PDGF binding characteristics are of no reliable predictive value in respect to the efficacy of suramin.

Use of athymic nude mice for in vivo studies of human growth-hormone-secreting pituitary adenomas

Human growth hormone (hGH)-secreting pituitary adenoma tissue of 31 acromegalic patients was transplanted subcutaneously onto 291 athymic nude mice. 37% of the transplanted adenoma fragments could be maintained vital up to 46 days. Histological examinations of the transplants revealed neither alterations in their morphological characteristics nor signs of growth. A maintenance or linear decline of hGH secretion of the transplants related to their vitality was observed by hGH radioimmunoassay. Estimation of graft vitality was improved by GH-releasing hormone (GHRH) stimulation in regular intervals. The rate of pituitary adenomas responding to GHRH was as high as in a major collective of acromegalic patients. Our method of positive selection of vital xenotransplanted hGH-secreting pituitary adenomas via hGH detection at regular intervals in combination with GHRH stimulation gives the opportunity of reliable in vivo research with these tumors.

Primary spinal malignant schwannoma: clinical, histological and cytogenetic findings

Of the 19 patients who presented between 1980 and 1990 to the Department of Neurosurgery, University of Hamburg, F. R. G. with malignant schwannoma, 5 patients suffered from primary malignant spinal schwannoma (mean age 44 years, only one patient with von Recklinghausen's disease). Here we report the clinical, histological, and cytogenetic features of the five cases with primary malignant spinal schwannoma and discuss the prognostic aspects of this rare tumor.

Chondromatosis of the choroid plexus: case report

We report the case of a patient with successful total removal of a previously undescribed intracranial tumor arising in the right lateral ventricle (probably of metaplastic origin). The histopathological examination revealed benign chondromatosis of the choroid plexus. The pathogenesis of this lesion, with special reference to synovial chondromatosis and to the differential diagnosis of solid neoplastic chondromas, their clinical features, and computed tomographic and magnetic resonance imaging findings, is presented and discussed.

Antigenic staining patterns of human glioma cultures: primary cultures, long-term cultures and cell lines

The immunocytochemical staining patterns of cultured glioma cells were investigated. Fifty nine individual cases were stained at different in vitro ages for glial fibrillary acidic protein, fibronectin, galactocerebroside, HNK-1/Leu 7, A2B5, vimentin, factor VIII and A4. Histologically, the cases were composed of eight low-grade astrocytomas, 11 high-grade astrocytomas, four low-grade oligodendrogliomas, seven high-grade oligodendrogliomas and 29 glioblastomas. The 45 cases were analysed within the first 3 weeks of culture, many of them as primary cultures. In 11 cases stainings were performed repeatedly at intervals of up to 6 months. Glial fibrillary acidic protein staining was positive in most of the early cultures of astrocytomas (low and high grade) and glioblastomas; expression in more than 50% of the cells was found in 1 of 5 low-grade astrocytomas, 5 of 11 high-grade astrocytomas and 14 of 29 glioblastomas. Two of the high-grade astrocytomas were stained once more after 6 weeks in culture and were found to be only 1% positive for glial fibrillary acidic protein but strongly positive for fibronectin. The same was true for five of the glioblastoma cases. Two of these cases remained glial fibrillary acid protein positive and developed into stable permanent cell lines. Only one case started with 1% of glial fibrillary acidic protein positive cells and later developed into a 99% glial fibrillary acidic protein positive cell line. Neither HNK-1/Leu 7 expression nor A2B5 staining appeared to have a relationship to the glial fibrillary acidic protein staining. It was observed that glial fibrillary acidic protein and HNK-1/Leu 7 were both 100% in some cases but that later one of the two antigens disappeared but not the other. The amount of glial fibrillary acidic protein staining does not allow the prediction of A2B5 staining. The study shows that initiation of primary cultures on an extracellular matrix yields more glial fibrillary acidic protein positive cells in primary cultures than have been found in other studies. It is concluded that only a rigid standardization of culture conditions will ensure the validity of comparisons of in vitro data obtained in primary cultures.

Culture of human brain tumors on an extracellular matrix derived from bovine corneal endothelial cells and cultured human glioma cells

Cell culture has become an integral part of the daily routine of most oncology laboratories. It has enabled researchers to investigate a wide range of cellular parameters in a defined system in which the experimental conditions can be controlled and repeated. Although the manufacturers of tissue culture materials are continually improving their products, cell attachment and initial survival of primary cultures from tumor cells are still problems in many laboratories. Many different approaches have been taken to circumvent this problem, and coating of tissue culture dishes with attachment enhancers, such as polyamino acids (1), fibronectin (2), laminin (3), and collagen (4), has been found helpful. For a long time, it was known that endothelial cells produce a basement membrane, and this led to the use of bovine corneal basement membrane by Gospodarowicz et al. (5,6), in their research into the phenomenon of regeneration and nonregeneration of corneal endothelium in different species. The application of this bovine corneal extracellular matrix (bECM) has since been greatly expanded (5,6). bECM has found broad approval, and has been used for mammary carcinoma (7), urological tumors (8), and different kinds of pituitary adenomas (9,10) as well as CNS tumors (11).

Growth factor biology and oncogene activation in human gliomas and their implications for specific therapeutic concepts

The failure of most available treatment modalities to improve the survival time and the quality of survival in patients with gliomas calls for the intense biological analysis of glial neoplasia. The untimely activation of cellular protooncogenes is often related to the process of neoplasia. Several protein growth factors as well as their cellular receptors have been identified as products of proto-oncogenes. Furthermore, these growth factors have been identified as glial mitogens in normal glial cell cultures as well as in tumors. The analysis of growth factor biology gains additional weight by the demonstration of autocrine growth factor secretion by tumor cells. The role of epidermal growth factor (EGF) and its receptor system in glial cell proliferation and differentiation is presented, with the speculation that the EGF receptor system may integrate the biological actions of many different factors, of which EGF itself may be least important. The literature on platelet-derived growth factor and insulin-like growth factors is reviewed, and the biology of fibroblast growth factor is presented in perspective with such phenomena as neovascularization and cell-matrix interactions.

Cyst fluids of malignant human brain tumors contain substances that stimulate the growth of cultured human gliomas of various histological type

The contents of 14 cysts that were located within human intracranial tumors were obtained at surgery by needle aspiration. These tumor cyst fluids (TCFs) were mostly derived from glial tumors (10 cases). TCFs from one metastasis from a mammary carcinoma, one cystic meningioma, one hemangioblastoma, and a cystic acoustic neurinoma were also included. These TCFs were added to primary cultures of human gliomas, established human glioma cell lines, and normal human arachnoid cells in culture. The presence of proliferation-promoting factors in all cyst fluids could be demonstrated. On the basis of the response patterns of the cultures, it was possible to distinguish different levels of growth autonomy and growth factor sensitivity among these cultures and to speculate about varying degrees of cellular autocrine activation. The TCFs appear to contain factors that are not normally present in fetal calf serum, which is a regular constituent of most cell culture media. Some primary cultured cells as well as cell lines react in an oversensitive manner to the addition of TCFs.

Spectrum of karyotypic aberrations in cultured human meningiomas

Twenty-two unselected cases of meningioma were initiated in tissue culture on an extracellular matrix derived from bovine corneal endothelial cells. The cultures were available for karyotypic analysis at passages 1 to 5, representing cultivation periods of up to two months. Histologically, the meningiomas were meningiotheliomatous (16 cases), fibrous (1 case), angiotheliomatous (1 case), microcystic (2 cases), and parenchymatous (2 cases). Two of the meningotheliomatous cases had histological signs of malignancy, another case showed increased signs of proliferation, and two cases were recurrences, one after a complete course of irradiation. In five cases no structural chromosome aberrations were found. Monosomy of chromosome 22 was found in six cases and was associated with other random aberrations. Clonal or random aberrations without monosomy 22 were present in 11 cases, including one case with trisomy 7 and another case with a stable translocation marker, t(4;7). In these latter two cases, EGF-receptor binding was not elevated, compared to other meningiomas. Our results illustrate that, in addition to the frequent involvement of chromosome 22, numerous other individual clonal karyotype aberrations exist in meningioma cell populations, reflecting the heterogeneity of biological and pathological findings.

Clinical efficacy of perioperative antimicrobial prophylaxis in neurosurgery--a prospective randomized study involving 159 patients

In a randomized study 87 patients received perioperative antibiotic prophylaxis with 2 x 2 g ceftriaxone (Rocephin) at the beginning of the operation and in the following morning. Seventy-two patients received no antibiotic prophylaxis. In patients receiving the prophylaxis, a lower incidence of infections was observed postoperatively in addition to a reduction in wound-healing disorders. Respiratory tract infections were more successfully prevented than urinary tract infections. The number of pathogenic bacteria detected in the group on receiving prophylaxis decreased. The positive effect of the perioperative administration of antibiotics was more evident in protracted operations, such as brain surgery, than in operations involving the spinal cord.

Floating thrombus in the internal carotid artery disclosed by B-mode ultrasonography

In a 44-year-old patient with transient cerebral ischaemia a large floating thrombus in the carotid bifurcation was detected by B-mode ultrasonography. To prevent further embolization the floating thrombus was removed by endarterectomy. The sonography findings were confirmed by operation and microscopy. Although migrating clots have long been recognized as a frequent cause of cerebrovascular accident, comparable cases have been rarely published. The problems involved in visualizing thrombi in the carotid artery by B-mode ultrasonography are discussed.

Brain tumours in children. A plea for an interdisciplinary working group

A considerable number of high risk brain tumours require an interdisciplinary approach with surgery, radiation and chemotherapy rather than one single therapeutic regimen. Children with a medulloblastoma must be subdivided into four different risk groups depending on the size of the tumour, on the age of the child and on cerebral spinal fluid cytology findings. The treatment protocol for ependymomas depends on the location of the tumour and on histological grading. Pineal region tumours can be successfully removed; further therapy depends on the type of the tumour. Children with hemispheric high grade astrocytomas gain substantially from local radiation therapy. The GPO (Gesellschaft für Pädiatrische Onkologie) has most recently taken the initiative to found a pediatric neuro-oncology working group in order to establish and to evaluate different treatment modalities.

Intramedullary spinal cord tumors resected with CO2 laser microsurgical technique: recent experience in fifteen patients

We have operated upon 15 intramedullary spinal cord tumors with the aid of a CO2 laser attached to the microscope. The operative technique is described. Most of the tumors were localized within the cervical spinal cord. Nine tumors were benign gliomas: 4 ependymomas, 1 subependymoma, 3 astrocytomas, and 1 ganglioglioma. Six were removed totally, and 3 were removed subtotally. The remaining 6 tumors consisted of 3 hemangioblastomas, 1 intramedullary neurofibroma, 1 lipoma, and 1 primary intramedullary melanoma. Neurological function postoperatively compared to the preoperative function of the upper extremities was unchanged in 13 patients (86.5%), improved in 1, and worse in 1 patient. In the lower extremities, the preoperative neurological status was unchanged in 11 patients (73.3%), improved in 1 patient, and worse in 3 patients (20%). Magnetic resonance imaging was superior to myelography and computed tomography in localizing these lesions. Enhancement with paramagnetic substances (e.g., gadolinium-DTPA) helps to localize solid tumor within cysts. Histological evaluation of small tissue biopsies or frozen section histology is unreliable. The entire lesion should be exposed in all cases, and an attempt should be made to remove the tumor totally or, if this is not possible, to resect as much of the center of the tumor as is possible until the cord is decompressed. The decision to administer further treatment is based on the histological features of the tumor.

[The biology of gliomas: growth factors and oncogene expression. A current review]

In recent years several proteins with in vitro cell growth promoting activity were chemically identified and termed growth factors. Their role in normal glial development has been studied in vitro in different defined systems. In addition it has been tried to elucidate their role in the biology of gliomas. Some clues were obtained from the study of growth factor receptors and the expression of oncogenes. It has to be assumed that from the correlation and synthesis of results obtained from studies of growth factors, oncogene expression, gliogenesis and cytogenetics there will emerge useful biological concepts for specific therapeutic approaches.

Biological and karyotypic characterization of a new cell line derived from human gliosarcoma

A cell line (NCE-G28) was established from the biopsy material of a human gliosarcoma of low histological differentiation. The initial cultures showed a mixed population of cells which in later stages became more uniform due to loss of slower growing constituents. The cells have been growing steadily for 20 months. A suspension of NCE-G28 cells injected s.c. as well as i.p. into nude mice produced solid tumors in all cases. Histologically these tumors closely resembled the original tumor. The original tumor, the nude mouse tumor, and NCE-G28 cells were immunochemically positive for glial fibrillary acidic protein as well as for neural plasma membrane antigen A2B5 expression. Two cell strains, 9B2C and 9B2E, were obtained by cloning of the initial cultures and another strain, NCE-G28T, was derived after explantation of a mouse heterotransplant. The two subclones were negative for glial fibrillary acidic protein expression but stained for cell surface fibronectin. NCE-G28T cells initially were positive for glial fibrillary acidic protein but lost this property within 8 months of cultivation. Karyotype analysis of NCE-G28 and the three strains revealed hyperdiploidy and six structurally altered marker chromosomes five of which were shared by nearly all cells. Receptors for epidermal growth factor were detected in all cell lines with the highest levels (about 300,000 receptors/cell) in the parental cell line. The epidermal growth factor receptors had an affinity of 2.5 nM (Kd) and by affinity cross-linking analysis a molecular weight of 170,000 was found. Initially, NCE-G28 cells responded to epidermal growth factor as well as fibroblast growth factor with increased rates of proliferation, while platelet derived growth factor had no effect. In higher passages the growth factor sensitivity was reduced. Using antibodies directed against synthetic protooncogene peptides the production of c-sis immunoreactive material was detected. NCE-G28 cells produce an autocrine factor which stimulated proliferation. This factor is present in conditioned medium and is active on cultured meningiomas and other glioma cell lines. NCE-G28 cells can be maintained in serum-free defined medium on plastic coated with fibronectin or an extracellular matrix from bovine corneal endothelial cells. The NCE-G28 cell line with its strains provide an in vitro model system in which the complexity of gliosarcoma cell populations and the interaction of the cloned cellular constituents can be studied.

Growth factors in cultured human glioma cells: differential effects of FGF, EGF and PDGF

Primary cell cultures were initiated from surgically obtained specimens from human gliomas. After 4-10 passages in vitro the cells from 18 individual cases were seeded onto cluster dishes and left to attach for 24 h in medium containing fetal calf serum. Thereafter the medium was changed to serumfree, defined conditions and the following growth factors were added: EGF 1.5 x 10-8 M, PDGF 35 ng/ml, FGF 80 pg/ml. The growth factors were added fresh every 2 days. After 9 or 11 days in culture, the cells on one multiwell-plate were counted. In 8 cases another set which was cultured also in a multiwell-plate but on glass cover slides was immunostained for glial fibrillary acidic protein (GFAP), fibronectin (FN), A2B5 and galactocerebroside (galC). The proliferative response pattern in consequence to the growth factor addition varied greatly between different cases. In all cases a pronounced proliferative response was accompanied by marked changes on the culture morphology. Usually the best proliferative response was obtained with PDGF (10 cases) or FGF (8 cases) whereas EGF was most effective only in one case. Two cases showed only minimal response, one of which was an oligodendroglioma D according to Ludwig and another a gliosarcoma which was re-evaluated after 1 year in culture. It could be noted, however, that FGF had a tendency to be less effective in the group of malignant astrocytomas. The staining pattern of the cultures with the afore mentioned markers was not affected by the growth factor treatment. The proliferative response usually resulted in increased staining for fibronectin and never an induction of GFAP. A2B5 staining was positive only in one case of gliosarcoma and galC staining was regularly negative.

Glioma biology in vitro: goals and concepts

Gliomas are heterogeneous in their cellular composition, affecting therapeutic efforts such as surgical removal, radiotherapy, chemotherapy and immunotherapy. 106 gliomas were taken into culture in our laboratory and 12 cell lines could be established there from. Experiments were carried out in as many early cultures as possible and with the constant experimental system of the cell lines. To subdivide and possibly classify the heterogeneous group of gliomas the following approaches emerged: Immunostaining of cells for glial markers such as GFAP, A4, A2B5, Leu 7 as well as fibronectin will allow one to distinguish different groups of glial cultures. Performance of growth factor sensitivity tests allows the assessment of major aspects of growth control in cultured gliomas. Cytogenetic evaluation in early cultures and correlation with the expression of oncogenes may yield useful information on mechanisms of escape from normal growth control. One of our cell lines (NCE-G28) in which cells switch from GFAP to fibronectin expression and transiently express the x-hapten may serve as a model to study crucial aspects of cellular differentiation. Using different extracellular matrices for the initiation of cultures even from very benign lesions with low proliferative potential it is possible to include these into comparative studies with glioblastomas.

Clinical and laboratory findings in patients with multiple meningiomas

A series of eight patients with multiple meningiomas is presented. Up to 14 meningiomas were diagnosed in one patient. The clinical and laboratory findings suggest that multiple meningiomas do not constitute a disease entity of their own featuring disease-specific clinical or laboratory findings. In our series we find a female predominance with seven female and one male patient. The histological findings were mixed, even within the individual cases. There are no consistent patterns of steroid receptor levels or chromosomal aberrations in the more recent cases in which these parameters could be investigated.

Does the timing of aneurysm surgery neglect the real problems of subarachnoid haemorrhage?

In 1984, in connection with the introduction of the calcium antagonist nimodipine, a new strategy for the treatment of subarachnoid haemorrhage (SAH) due to ruptured aneurysm was developed in our hospital. With no rigid regard to "timing" all patients undergo surgery as soon as possible. The only exception being those in Hunt and Hess grades IV and V without space-occupying intracranial haemorrhage and those bearing aneurysms of the vertebrobasilar circulation that are difficult of access. As soon as the risk of rebleeding has been eliminated surgically an active therapy against the possible consequences of SAH--cerebral vasospasm and simultaneous disturbances of autoregulation--is started. It consists in lowering the increased intracranial pressure, raising of mean arterial pressure and improving of rheological properties of the blood in order to prevent delayed build-up of neurological deficit due to ischaemia. It goes without saying that calcium antagonists are given from the very beginning of the patient's treatment even before operation. The advantages of this therapeutic concept are demonstrated by two series of non-selected consecutive patient material. The first series (A; n = 135) was treated between 1981 and 1984 before the change in treatment strategy, the second (B; n = 183) from 1984 to 1986 after that change. The overall mortality in series A was 27%, that in series B 20%. Operative mortality could be reduced from 22% to 16% in patients having undergone early operation and from 6% to 2% in patients with late surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

[Prognosis and quality of life following tumors in the pineal region in childhood]

At the department of neurosurgery and pediatrics of the University Hospital of Hamburg 18 children with pineal region tumors were treated by surgical removal and craniospinal axis radiation. Total or nearly total removal was achieved in 13 cases. In case of astrocytoma and pineocytoma no further treatment was performed. Children with germinoma, pinealoblastoma and teratoma underwent craniospinal axis radiation postoperatively. All children thus treated, except one with a highly malignant pinealoblastoma, are so far relapse-free. Two patients with germinoma and two patients with malignant mixed teratoma, which showed extensive growth and/or primary metastases already at admission died. Subject of this report is an assessment of quality of live and a comprehensive follow-up of neurological, endocrinological and psychointellectual conditions of the surviving children. Parent assessment of quality of life indicate for all but two children life quality as excellent or reasonable. One child was disabled by severe motor dysfunction, visual defects and convulsions. In two children minor neurological handicap was found. Minor oculomotor dysfunction was the most frequent neurological finding. Four children showed endocrinopathies. In three cases tumor associated panhypopituitarism persisted after treatment. Only one child developed growth hormone and ADH deficit succeeding surgery and craniospinal axis radiation. The children were examined with a neuropsychological test-battery. In four children severe neuropsychological deterioration was found. Three children showed no remarkable deterioration, five only minor or moderate psychological deficits. Generally verbal intelligence seemed to be on average, non-verbal intelligence and ability for concentration showed decreased scores.