Improving Holistic Care Skills for Advanced Practice Registered Nurses: Integration of a Complementary and Alternative Medicine Course into a Doctor of Nursing Practice Curriculum

BACKGROUND

Complementary alternative medicine (CAM) is an expanding domain of healing practices harmonized with Western medicine to provide comprehensive treatment of individuals as holistic beings. Patients and healthcare providers worldwide are increasingly inviting and employing CAM practices into healthcare delivery routines. Implementation of courses to introduce CAM into Advanced Practice Registered Nurse (APRN) programs exposes future practitioners to current best practices for integrative treatment strategies and encourages consideration when developing a holistic patient-centered care plan.

OBJECTIVE/METHODS

A case presentation of an interprofessional CAM course delivered to military graduate nursing students with a pretest posttest course survey to evaluate student's confidence and knowledge of CAM theory and practices. The format included online modules, evidence-based literature critique, knowledge checks, and an immersive hands-on immersion experience.

RESULTS

A total of 240 pre-/postcourse surveys were completed by military graduate nursing students (N = 140) participating in a CAM course. Statistically significant increases in CAM knowledge, communication, and skills confidence levels were found. Following participation in the course, nearly all students (97%) agreed CAM is important and benefits future advanced practice.

CONCLUSION/NURSING IMPLICATIONS

CAM is a compendium of holistic healing modalities increasingly being utilized by patients worldwide with similar requests for alternative care techniques from healthcare providers. Military APRN students participating in a CAM course increased knowledge and confidence, and garnered appreciation for an expanded skill set to augment future practice. Case presentation is compelling for standard inclusion of CAM and similar graduate interprofessional courses into all APRN programs.

Temporal lobe surgery in Germany from 1988 to 2008: diverse trends in etiological subgroups

BACKGROUND AND PURPOSE

In the epilepsy community, there is talk that the number of classical patients with early onset temporal lobe epilepsy (TLE) and Ammon's horn sclerosis (AHS) is decreasing. This is counterintuitive, considering the success story of epilepsy surgery, improved diagnostic methods and the current recommendation of early admission to surgery. In order to recognize trends, the development of temporal lobe surgery over 20 years in three major German epilepsy centers was reviewed.

METHODS

Age at surgery and duration of epilepsy, which was differentiated according to histopathology (AHS, developmental, tumor, vascular), year of surgery and center, were evaluated in a cohort of 2812 patients from three German epilepsy centers who underwent temporal lobe surgery between 1988 and 2008. The analysis was carried out for the pooled cohort as well as for each center separately.

RESULTS

Of all patients, 52% showed AHS. Compared with other pathologies, the AHS group had the earliest epilepsy onset and the longest duration of epilepsy. Across five time epochs, the diagnosis of AHS increased in the first epoch, remaining constant thereafter. Contrary to the trends in other pathologies, in the AHS group the mean age of patients at surgery increased by 7 years and the duration of epilepsy until surgery increased by 5 years. This trend could be replicated in all three centers. As initially hypothesized for all groups, age and duration of epilepsy in other pathology groups remained constant or indicated earlier submission to surgery.

CONCLUSIONS

During the first few years studied, most probably due to progress in brain imaging, the proportion of patients with AHS increased. However, despite stable numbers over time, and contrary to the trends in other pathology groups, age and duration of epilepsy in mesial TLE with AHS (mTLE + AHS) increased over time. This supports the hypothesis of a decreasing incidence of AHS. This trend is discussed with respect to disease-modifying factors which have changed the incidence of classical mTLE + AHS or, alternatively, to recent developments in antiepileptic drug treatment, the appraisal of surgery and economic incentives for treatment options other than surgery.

A comprehensive analysis of early outcomes and complication rates after 769 craniotomies in pediatric patients

PURPOSE

Perioperative complications following craniotomy in pediatric neurosurgery have received little attention. We analyzed perioperative complications and early outcomes following craniotomy in a large cohort of pediatric patients.

METHODS

A retrospective chart review identified 769 operations (27 % epilepsy surgery, 26 % trauma, 21 % tumor, 7 % vascular, 4 % infections, 14 % other, and 88 % supratentorial) in 641 patients <16 years (mean age 8.5 years). We recorded all perioperative complications and functional outcomes 30 days after surgery.

RESULTS

Excluding epilepsy surgery cases, 17.5 % patients had emergency surgery. There were 38 new major neurological deficits (5.0 %; excluding deficits incurred as part of the surgical strategy). New neurological deficits occurred more frequently following operations for brain tumors, when compared to other surgeries (P < 0.001), and after surgery for infratentorial lesions (P < 0.001). Local complications occurred in 3.9 %, systemic complications in 2.5 % of patients. Ventricular shunting or endoscopic ventriculostomy was necessary in 87 patients (11.3 %). Surgical mortality was 2.0 % (including moribund patients after trauma or vascular incidence). Preoperative Karnofsky Performance Index (KPI) and the incurrence of new neurological deficits proved the most powerful predictors of functional outcome. Emergency surgery or repeat craniotomies were not correlated with increased rates of local complications.

CONCLUSIONS

Craniotomies for pediatric patients carry a low morbidity and mortality. Systemic complications seem to occur less often in the pediatric than in the adult population. Good surgical outcomes require a proper balance between local pediatric neurosurgical care for emergency cases and centralized treatment of more difficult cases.

Peripheral immunization against malignant rat glioma can induce effective antitumor immunity in the brain

Using two malignant rat glioma cell lines, we tested to what extent peripheral immunization could affect tumor growth in the brain of syngeneic rats. Peripheral subcutaneous (s.c.) immunization was performed with autologous Newcastle-disease-virus (NDV)-infected or non-infected live tumor cells. Thus immunized rats or non-immunized controls were intracerebrally implanted with increasing numbers of the respective malignant glioma cells. Without immunization the mean survival time after intracerebral implantation of 1x10(4) TZ363 or RG2 glioma cells was 9 and 29 days respectively. After s.c. immunization with either NDV-infected or non-infected TZ363 cells only 25% or less of challenged animals developed tumors in the brain. Immunization with NDV only had no effect. In RG2 glioma, s.c. immunization had no effect on tumor growth in the central nervous system and on survival time, no matter what kind of vaccine was used. These results clearly show, that in principle the efferent arm of the anti-tumor response can be effective accross the blood-brain barrier and extend into the microenvironment of the central nervous system. Whether or not glioma lines can induce this immunity and respond to it, seems to depend on their individual immunobiological characteristics.

Seizure outcome, functional outcome, and quality of life after hemispherectomy in adults

BACKGROUND

Functional hemispherectomy is a well-established method in childhood epilepsy surgery with only a few reports on its application in adults.

METHODS

We report on 27 patients (median age 30 years, range 19-55) with a follow-up of more than 1 year (median 124 months, range 13-234). Etiology was developmental in two (one schizencephaly, one hemimegalencephaly), acquired in 21 (two hemiatrophy, 17 porencephaly, two postencephalitic), and progressive in four (Rasmussen's encephalitis).

RESULTS

At last available follow-up, 22 patients were seizure free (81 % ILAE class 1), one had auras (4 % ILAE class 2), one had no more than three seizures per year (4 % ILAE class 3). Thirty-seven percent were without antiepileptic drugs. Seventeen patients of 20 responding patients stated improved quality of life after surgery, one patient reported deterioration, and two patients reported no difference. Additionally, a self-rated postoperative functional status and changes compared to the pre-operative status was assessed. Six patients improved in gait, ten remained unchanged, and four deteriorated. Three patients improved in speech, none deteriorated. Hand function got worse five times, and in 15 cases remained unchanged. There was no mortality, one bone flap infection, and one subdural hematoma. Hydrocephalus was seen in three cases (12 %).

CONCLUSIONS

It is possible to achieve good seizure outcome results despite long-standing epilepsy across a variety of etiologies, comparable to epilepsy surgery in pediatric patients. Adult patients do not have to expect more problems with new deficits, appear to cope quite well, and mostly profit from surgery in several quality of life domains.

Complementary therapy use in patients with glioma: an observational study

OBJECTIVE

Despite novel multimodal therapeutic approaches, the vast majority of glial tumors are not curable. Patients may search for complementary therapies in order to contribute to the fight against their disease or to relieve symptoms induced by their brain tumor. The extent of the use of complementary or alternative therapies, the patients' rationale behind it, and the cost of complementary therapy for gliomas are not known. We used a questionnaire and the database of the German Glioma Network to evaluate these questions.

METHODS

A total of 621 questionnaires were available for evaluation from patients with glial tumors of WHO grades II to grade IV. The patients were recruited from 6 neuro-oncologic centers in Germany. Complementary therapy was defined as methods or compounds not used in routine clinical practice and not scientifically evaluated.

RESULTS

Forty percent of the responding patients reported the use of complementary therapies. Significant differences between the group of complementary therapy users and nonusers were seen with respect to age (younger > older), gender (female > male), and education (high education level > low education level). The motivation for complementary therapy use was not driven by unsatisfactory clinical care by the neuro-oncologists, but by the wish to add something beneficial to the standard of care.

CONCLUSIONS

In clinical practice, patients' use of complementary therapies may be largely overseen and underestimated. The major motivation is not distrust in conventional therapies. Neuro-oncologists should be aware of this phenomenon and encourage an open but critical dialogue with their patients.

Postsurgical intracranial hypotension: diagnostic and prognostic imaging findings

BACKGROUND AND PURPOSE

CSF loss with consecutive intracranial hypotension has been discussed as a possible pathogenetic mechanism in poor clinical outcome after uneventful neurosurgery and appears to be correlated to specific imaging findings. The purpose of this study was to describe the clinical and imaging findings of symptomatic intracranial hypotension likely induced by wound suction drainage.

MATERIALS AND METHODS

This is a review of previously published cases of patients in whom this condition developed after uneventful intracranial surgery. We performed an analysis of 3 more cases, of which 2 occurred after spinal surgery with accidental dural opening.

RESULTS

Sixteen patients who remained unconscious or did not become fully responsive after surgery showed symmetric bilateral thalamic/basal ganglia signal intensity changes on CT and MR imaging studies. Of these 16 patients, 4 died and 2 also had brain stem signal intensity changes. All patients had rapid and distinct intraoperative and postoperative CSF loss documented on CT and/or MR imaging studies by a transient increase of the sag ratio, defined as maximal anteroposterior midbrain diameter by maximal bipeduncular diameter.

CONCLUSIONS

The clinical course and typical MR imaging findings characterize the disease entity postsurgical intracranial hypotension. These findings also underline the potential danger of wound suction drainage in the case of possible CSF loss.

Intraoperative preservation of corticospinal function in the brainstem

BACKGROUND

The corticospinal tract features a largely exposed course through the brainstem, and is therefore at risk in many brainstem-related procedures. No large case series on motor-evoked potential (MEP) monitoring during brainstem surgery have been reported as yet.

OBJECTIVE

To understand intraoperative MEP changes during brainstem-related surgery, and to explore the value of MEP monitoring for preventing permanent new paresis.

METHODS

Myogenic MEPs after transcranial electrical train stimulation were monitored in 70 cases of intraparenchymal (n = 39) and extraparenchymal (n = 31) brainstem-related tumours and vascular lesions. MEP recordings failed in another five cases. Motor outcome and intraoperative MEP results were documented prospectively and correlated for this study.

RESULTS

Significant MEP changes occurred in 46% of cases. Stable and only reversibly deteriorated MEPs warranted unimpaired motor outcome (n = 50, 71% of all cases). Irreversible deterioration and reversible loss (n = 19, 27%) indicated a 37% risk for transient deficit. Irreversible loss (one case, 1.5%) predicted permanent paresis. MEPs and motor outcome correlated equally well in intra- and extraparenchymal lesions. Somatosensory-evoked potentials (SEPs) did not reliably reflect motor outcome. Permanent motor deficit occurred in one out five cases (20%) with failed MEP recordings.

CONCLUSIONS

MEP monitoring-as opposed to SEPs-is a valid indicator of corticospinal function in brainstem-related surgery, independent from the type of lesion operated on. New deficit occurs only after more pronounced MEP changes than in supratentorial surgery, but complete loss as in spinal surgery is not required. MEPs may help to prevent permanent new paresis.

Peri-operative glucocorticoid replacement therapy in transsphenoidal pituitary adenoma surgery: a prospective controlled study

BACKGROUND

We set out to prospectively study the peri-operative changes of the hypothalamic-pituitary-adrenal axis (HPA), and to test the hypothesis that the peri-operative corticoid replacement regimen used at the authors' institution in patients with impaired HPA undergoing transsphenoidal pituitary adenoma surgery is adequate.

METHOD

Thirty seven patients (21 females, 16 males, mean age 50.6 years) underwent transsphenoidal pituitary adenoma surgery (mean tumour diameter 20.6 mm, 13 tumours hormone-secreting). The HPA functions of these patients were classified as impaired (group A, n = 15) or preserved (group B, n = 22) according to the results of a pre-operative corticotrophin releasing-hormone test (CRHT). Eleven patients (9 female, 2 male, mean age 53.6 years) without pituitary adenomas and with a preserved HPA (as assessed by medical history and morning serum cortisol (MSC) measurements), undergoing decompressive surgery for degenerative lumbar disc disease, were also studied (group C). On the day of surgery, the patients of group A received 100 mg hydrocortisone (HC) replacement therapy, which was thereafter gradually tapered off in a standardised fashion. The patients of groups B and C were not treated with corticoids. Pre-operative, intra-operative and post-operative variables of these three patient groups were compared.

FINDINGS

The urinary free cortisol excretion (UFC) in group A declined from 6732 +/- 7683 microg/d on the day of surgery to 305 +/- 358 microg/d on the 10(th) post-operative day. In group B, the respective UFC values were 12,851 +/- 16,278 microg/d and 223 +/- 235 microg/d. In both of these groups, the mean UFC did not fall into the normal range during the first ten post-operative days. On none of the post-operative days, was there a significant difference between the UFC of groups A and B. The UFC values of group C dropped from 177 +/- 157 microg/d on the day of surgery to 87 +/- 61 microg/d on post-operative day six, reaching the normal range from the 2(nd) post-operative day onwards. All UFC values of group C were significantly lower than those of group A and B. None of the evaluated clinical, laboratory and MRI parameters, as disclosed by uni- and multivariate analysis, showed any significant influence on the peri-operative UFC values.

CONCLUSIONS

The peri-operative UFC of pituitary adenoma patients with preserved HPA was very high, as compared to patients with degenerative lumbar disc disease. The present study showed for the first time, that the proposed regimen of peri-operative corticoid replacement therapy used in patients with pituitary adenomas and impaired HPA raised cortisol levels to match the physiological increase of UFC in patients with pituitary adenoma surgery and preserved HPA. However, although statistically not significant, the UFC of patients with pituitary adenomas and preserved HPA seemed considerably higher on the day of surgery than in patients with pituitary adenomas and HPA impairment. Although there is no evidence to make it mandatory, administration of 150 mg instead of 100 mg HC substitution on the day of pituitary adenoma surgery in patients with HPA impairment may be prudent.

Limbic encephalitis as a precipitating event in adult-onset temporal lobe epilepsy

OBJECTIVE

Temporal lobe epilepsy with hippocampal sclerosis (TLE-HS) is the most frequent diagnosis in autopsy and surgical epilepsy series. TLE-HS usually starts during childhood or adolescence. There have been few studies of adult-onset disease. We recognized that some adult individuals have evidence of limbic encephalitis (LE), an autoimmune condition of adult life, which we proposed might lead directly to this syndrome.

METHODS

We performed a retrospective analysis of history, clinical and paraclinical findings, brain MRI, and outcome of surgical treatment including histopathology (if available) of all patients with TLE-HS presenting to this tertiary center within 6 years of epilepsy onset between 1999 and 2005.

RESULTS

Thirty-eight patients were identified, with median age at epilepsy onset of 37.8 years. Eleven patients (29%) were classified as having secondary HS (e.g., after head trauma, febrile seizures). Seven patients (11%) were classified as idiopathic. However, 9 patients (24%) had a diagnosis of definite LE, and another 11 individuals (29%) showed the typical LE pattern of MRI findings with hippocampal swelling evolving into atrophy with continuous FLAIR/T2 signal increase; they were diagnosed as possible LE. Bilateral abnormalities were more frequent in the two LE subgroups (60%) than in the two non-LE subgroups (22%; p = 0.025). Histopathology was performed in one patient with possible LE shortly after disease onset and showed a typical T cell infiltration and loss of hippocampal neurons.

CONCLUSIONS

Temporal lobe epilepsy with hippocampal sclerosis can manifest in adult life. Around half the patients have evidence consistent with an autoimmune process. If confirmed, this should have implications for diagnosis, prevention, and treatment.

Delayed Postoperative Hyponatremia Followed by Acute Renal Failure in a Patient with an ACTH-secreting Microadenoma of the Pituitary

The selective transsphenoidal adenomectomy of an ACTH-secreting microadenoma was followed by clinically symptomatic delayed hyponatremia in an otherwise healthy patient. During mild fluid restriction for the treatment of the hyponatremia, acute renal failure occurred. The renal failure was resolved by treatment with furosemide. Fluid restriction is considered a standard therapeutic approach for the treatment of this probably SIADH-induced hyponatremia. Until now, acute renal failure has not been reported under these circumstances. This unique case demonstrates the need of close monitoring of patients with delayed hyponatremia following pituitary surgery.

Focal cortical dysplasia: long term seizure outcome after surgical treatment

BACKGROUND

Studies of long term outcome after epilepsy surgery for cortical malformations are rare. In this study, we report our experience with surgical treatment and year to year long term outcome for a subgroup of patients with focal cortical dysplasia (FCD).

METHODS

We retrospectively analysed the records of 49 patients (females n = 26; males n = 23; mean age 25 (11) years) with a mean duration of epilepsy of 18 years (range 1-45). Preoperative MRI, histological results based on the Palmini classification and clinical year to year follow-up according to the International League Against Epilepsy (ILAE) classification were available in all patients.

RESULTS

98% of patients had a lesion on preoperative MRI. In addition to lobectomy (n = 9) or lesionectomy (n = 40), 14 patients had multiple subpial transections of the eloquent cortex. The resected tissue was classified as FCD type II b in 41 cases with an extratemporal (88%) and FCD type II a in 8 cases with a temporal localisation (100%). After a mean follow-up of 8.1 (4.5) years, 37 patients (76%) were seizure free, a subgroup of 23 patients (47%) had been completely seizure free since surgery (ILAE class 1a) and 4 patients (8%) had only auras (ILAE class 2). Over a 10 year follow-up, the proportion of satisfactory outcomes decreased, mainly within the first 3 years. During long term follow-up, 48% stopped antiepileptic drug treatment, 34% received a driver's license and 57% found a job or training.

CONCLUSION

Surgical treatment of epilepsy with FCD is not only successful in the short term but also has a satisfying long term outcome which remains constant after 3 years of follow-up but is not associated with better employment status or improvement in daily living.

Present practice and perspective of evaluation and surgery for temporal lobe epilepsy

Surgery for temporal lobe epilepsy refractory to medical treatment is a promising treatment option. After a short overview of historical developments in this field, we describe the present practice of presurgical evaluation and resection strategies as practiced at our institution and review the corresponding publications from other centers. We will be trying to outline major future developments for the surgical therapy of temporal lobe epilepsy based on present trends.

DNA methylation and allelic losses on chromosome arm 14q in oligodendroglial tumours

Cytogenetic and molecular genetic studies have shown frequent losses on the long arm of chromosome 14 in different types of human gliomas. Using differential methylation hybridization as a genome-wide screening approach to determine DNA methylation patterns in gliomas, we recently identified two DNA fragments in 14q23.1 (CGI-clone musical sharp396) and 14q32.12 (CGI-clone musical sharp519) that were differentially methylated between astrocytic gliomas and mixed oligoastrocytomas. To validate this observation, we examined these 14q32.12 locus for methylation in an extended series of 43 astrocytic and oligodendroglial gliomas. All tumours were additionally investigated for loss of heterozygosity (LOH). Microsatellite analysis showed LOH in seven of 28 (25%) oligodendroglial tumours and three of 15 (20%) astrocytic tumours. Seven tumours demonstrated LOH at all informative 14q loci whereas three tumours carried partial deletions defining a commonly deleted region at 14q22.3-q32.1 between the microsatellite markers D14S282 and D14S995. Methylation-specific PCR analysis of the 14q32.12 locus revealed hypermethylation in 12 of 43 gliomas (28%). Hypermethylation was restricted to tumours with oligodendroglial differentiation (12 of 28 tumours, 43%). However, none of the hypermethylated tumours demonstrated LOH on 14q and vice versa. In total, 19 of 28 oligodendroglial tumours (68%) showed either hypermethylation at the 14q32.12 locus or LOH at 14q22.3-q32.2. Taken together, our data lend further support for the location of one or more yet to be identified glioma-associated tumour suppressor gene(s) on 14q. In addition, the restriction of 14q32.12 methylation to oligodendroglial tumours suggests a role for epigenetic DNA modifications in these particular gliomas.

Firing pattern and calbindin-D28k content of human epileptic granule cells

In the hippocampus of chronic temporal lobe epilepsy, many abnormalities in structure and function have been described but their pathophysiological relevance often is poorly understood. In this study, we asked whether there may be a link between changes in the firing pattern and the loss of the calcium binding protein calbindin-D28k in epileptic hippocampal granule cells. Using the perforated patch-clamp technique, we investigated granule cells in slices prepared from human hippocampi removed for the treatment of pharmacoresistant temporal lobe epilepsy. Granule cells in hippocampi without significant signs of structural damage (lesion group) displayed a firing pattern indistinguishable from that of rodent granule cells and were strongly labeled with anti-calbindin-D28k antibodies. In contrast, half of granule cells in sclerotic hippocampi (HS group) showed an altered firing pattern and a severe loss of calbindin-D28k. While these cells show passive membrane properties comparable to cells of the rodent and lesion group, they lack the medium afterhyperpolarization and display only a weak spike frequency adaptation. On the other hand, granule cells in the HS group have an increased action potential threshold and an enlarged fast afterhyperpolarization. Applying post-recording immunohistochemistry to individual electrophysiologically characterized granule cells, we show that the loss of calbindin-D28k is not causally related to any of the changes in firing pattern. Both alterations seem to occur during the course of temporal lobe epilepsy, with the firing pattern being affected earlier than the calbindin-D28k content. In conclusion, we propose that it is the combination of the altered intrinsic excitability of granule cells with the amplified and prolonged synaptic input from perforant path fibers previously described in the epileptic dentate area which promotes tonic, non-adapting, high frequency firing of granule cells and thereby strongly augments the excitability of the hippocampus.

Frequent loss of chromosome 9, homozygous CDKN2A/p14ARF/CDKN2B deletion and low TSC1 mRNA expression in pleomorphic xanthoastrocytomas

The molecular pathogenesis of pleomorphic xanthoastrocytoma (PXA), a rare astrocytic brain tumor with a relatively favorable prognosis, is still poorly understood. We characterized 50 PXAs by comparative genomic hybridization (CGH) and found the most common imbalance to be loss on chromosome 9 in 50% of tumors. Other recurrent losses affected chromosomes 17 (10%), 8, 18, 22 (4% each). Recurrent gains were identified on chromosomes X (16%), 7, 9q, 20 (8% each), 4, 5, 19 (4% each). Two tumors demonstrated amplifications mapping to 2p23-p25, 4p15, 12q13, 12q21, 21q21 and 21q22. Analysis of 10 PXAs with available high molecular weight DNA by high-resolution array-based CGH indicated homozygous 9p21.3 deletions involving the CDKN2A/p14(ARF)/CDKN2B loci in six tumors (60%). Interphase fluorescence in situ hybridization to tissue sections confirmed the presence of tumor cells with homozygous 9p21.3 deletions. Mutational analysis of candidate genes on 9q, PTCH and TSC1, revealed no mutations in PXAs with 9q loss and no evidence of TSC1 promoter methylation. However, PXAs consistently showed low TSC1 transcript levels. Taken together, our study identifies loss of chromosome 9 as the most common chromosomal imbalance in PXAs and suggests important roles for homozygous CDKN2A/p14(ARF)/CDKN2B deletion as well as low TSC1 mRNA expression in these tumors.

Correlation of health-related quality of life after surgery for mesial temporal lobe epilepsy with two seizure outcome scales

PURPOSE

The objective of this study was to correlate health-related quality of life (HRQOL) after surgery for mesial temporal lobe epilepsy, as revealed by a postoperative screening tool, to different modalities of seizure outcome classification (Engel, International League Against Epilepsy (ILAE)).

METHOD

One hundred twenty-eight of one hundred forty consecutive patients returned a HRQOL questionnaire at a mean of 36 months after selective amygdalohippocampectomy. Patients answered in two ways: with an absolute estimation (values 1-4) and with a self-rated relative change (-1, 0, +1) after surgery.

RESULTS

Eighty patients were seizure- and aura-free (63.3% ILAE 1), 16 continued to have auras (12.5% ILAE 2), and 13 experienced 1-3 seizure days per year after surgery (10.2% ILAE 3). Ninety-two patients were classified seizure-free (71.9% Engel I), and 17 had two or fewer seizures per year (13.3% Engel II). Of 110 patients in ILAE 1-3, 100 (91%) stated good or even very good postoperative HRQOL, and 99 (90.0%) reported improvements in HRQOL. Only 9 of the remaining 18 (50%) reported good or very good HRQOL after surgery (P=0.01). Corresponding results were obtained with Engel classes I and II, suggesting a trend toward ILAE 1-3 and Engel I and II as overall satisfactory outcomes. A more detailed HRQOL assessment yielded lowest scores in the cognitive domain, and a significant correlation of self-rated changes in cognitive functioning with seizure control (P=0.01). Changes in physical capabilities and mood were significantly better with satisfactory seizure outcome (P=0.006 and P<0.001, respectively), whereas the social aspects were not significantly dependent on seizure outcome (P=0.06).

CONCLUSION

Correlation of HRQOL and seizure control suggested that ILAE 1-3 and Engel I and II most likely represent overall satisfactory outcome. Subdomain analyses revealed cognitive abilities as the most critical feature associated with seizure control, whereas social aspects remained mainly stable.

Interinstitutional variance of postoperative radiotherapy and follow up for meningiomas in Germany: impact of changes of the WHO classification

OBJECTIVE

To document and critically analyse the impact of the revised WHO 2000 histological classification for meningiomas on postoperative radiotherapy/radiosurgery indications and MRI follow up protocols.

METHODS

The current (2000) WHO classification was used to grade 57 meningiomas treated surgically at one institution. These had been reviewed previously in 1999. All German neurosurgical departments carrying out intracranial microsurgery were asked to detail their guidelines for radiation therapy and follow up for meningiomas of different WHO grades.

RESULTS

Use of the current criteria downgraded seven of 15 atypical meningiomas (WHO grade II, MII) to grade I (MI), and four of six anaplastic tumours (WHO grade III, MIII) to grade II. Indications for radiotherapy/radiosurgery and MRI follow up protocols varied substantially with the histological grade and between institutions--for example, after an incomplete resection, radiotherapy/radiosurgery recommendations differed between MI and MII in 30 of 58 units (52%), and between MII and MIII in 34 of 56 units (61%).

CONCLUSIONS

Correlative studies combining treatment and outcome data with a standardised histopathological analysis are warranted to define properly the indications for radiotherapy/radiosurgery and follow up protocols after surgery for meningiomas of different histological grades. The use of changing grading paradigms during recent years renders decision making based on local and published experience difficult. The relatively large number of meningiomas classified as atypical/WHO grade II in current practice would argue against an uncritically aggressive approach to these tumours.

Low-Grade Gliomas - Current Concepts

Diffuse astrocytomas, oligodendrogliomas, and oligoastrocytomas (mixed gliomas) WHO grade II, pleomorphic xanthoastrocytomas (PXAs), pilocytic astrocytomas, and subependymal giant cell astrocytomas (SEGAs) are often referred to as low-grade gliomas. WHO grade II astrocytomas, oligodendrogliomas, and mixed gliomas are characterized by their infiltrative growth, frequent tumor recurrence and a more than 50 % risk for malignant progression. In contrast, pilocytic astrocytomas and SEGAs are circumscribed tumors amenable to a (radio)surgical cure. There are few universally accepted guidelines for the treatment of low-grade gliomas. In this review, three neurosurgeons, a neurologist, a neuropathologist, and a radiation oncologist discuss some of the difficult issues surrounding the diagnosis and treatment of low-grade gliomas from their individual points of view (i. e., classification and neuropathology, MR imaging, stereotactic biopsy, microsurgery, interstitial radiotherapy/brachytherapy, radiotherapy, wait and see strategy).

Greater functional recovery after temporal lobe epilepsy surgery in children

The purpose of our study is to evaluate whether children recover better than adults from memory deficits as a consequence of temporal lobe surgery. We compared 3 and 12 month outcomes obtained in children and adults with medically refractory epilepsy. Each candidate underwent temporal lobe resection for seizure control and children were matched with regard to pathology, onset of epilepsy, side of surgery and type of surgery with adults (N = 30 for each group, mean age at surgery 13 versus 30 years). Three months after surgery, both left-resected groups displayed a significant decline in verbal learning capacity. During the following 9 months, only the children recovered and were able to reach their preoperative level 1 year after surgery. The left-resected adults remained, for the most part, on their low level and one year after surgery, they were still significantly worse than at the time of their preoperative examination. The right-resected adults experienced a deterioration in visual memory 1 year after surgery relative to the results of the short-term follow-up; the children improved. The children also had a better outcome with regard to attentional functions and, as a trend, a better seizure outcome (Engel Outcome I--1 year after surgery: 63% adults, 80% paediatric patients). Our neuropsychological data provide evidence of greater plasticity and compensational capacity in childhood. The results can be taken as a strong argument for early surgical intervention.

Famili�re Kavernome des Zentralnervensystems

In 1928, Hugo Friedrich Kufs reported on a family with cerebral, retinal, and cutaneous cavernous malformations. Since then, more than 300 families with inherited cavernous malformations have been reported. Genetic studies showed three loci, on chromosomes 7q21-q22 (with the gene CCM1), 7p15-p13 (CCM2), and 3q25.2-q27 (CCM3). The gene product of CCM1 is Krit 1 (Krev interaction trapped 1), a protein interacting with angiogenesis by various mechanisms. Recently, CCM2 has also been identified; its product is a protein which might have a function similar to that of Krit 1. However, the CCM3 gene has still not been found. In this study, we present clinical and genetic findings on 15 German families.

Expression analysis of metabotropic glutamate receptors I and III in mouse strains with different susceptibility to experimental temporal lobe epilepsy

Increased hippocampal excitability constitutes a pathogenetic hallmark of pharmacoresistant human temporal lobe epilepsy (TLE). Metabotropic glutamate receptors (mGluRs) can be subdivided into three classes based on sequence homologies, mechanisms of signal transduction as well as pharmacological characteristics. Generally, class I mGluRs mediate neuronal excitation whereas activation of class II and III mGluRs decreases synaptic transmission. Changes in expression of class I and III mGluR subunits have been described in human TLE. It remains to be determined whether altered mGluR expression relates to differences in seizure susceptibility or hippocampal damage. Here, we examine the transcription levels of mGluRs class I (mGluR1 and 5) and III (mGluR4 and 7) in experimental TLE and correlate differential mGluR subunit expression with mouse-strain-dependent susceptibility to TLE induced by pilocarpine. Expression of mGluRs 1, 4, 5 and 7 was determined in epileptic dentate gyrus granule cells (DG) in CD1, C57BL/6 and FVB/N mice by real time RT-PCR. FVB/N mice appear significantly more vulnerable to pilocarpine-induced seizures than C57BL/6 and CD1 strains. RT-PCR analysis demonstrates an increased expression of inhibitory mGluR 4 and downregulation of excitatory mGluR 1 in epileptic CD1 mice and a decrease of the excitatory mGluRs 1 and 5 in C57BL/6 (p<0.05, n=6 each) but not in the FVB/N strain. These results correlate differential expression of excitatory class mGluR I and inhibitory class mGluR III to seizure susceptibility and hippocampal damage. Our data suggest mGluRs class I and III as interesting potential therapeutic targets to interfere with hippocampal epileptogenesis and hyperexcitability.

Lesional mesial temporal lobe epilepsy and limited resections: prognostic factors and outcome

OBJECTIVES

To evaluate the influence of clinical, investigational, surgical, and histopathological factors on postoperative seizure relief in patients with mesial temporal lobe epilepsy (MTLE) due to lesions other than ammonshornsclerosis (AHS).

METHODS

Of 738 patients operated for TLE, 78 patients underwent limited resections for lesional MTLE (1990-2000). Seventy four patients with a follow up of more than one year were included. The preoperative clinical, neuropsychological, electroencephalogram, and neuroimaging characteristics were prospectively collected in a database. The histopathological material was re-examined.

RESULTS

The mean follow up was 49 months. Fifty eight patients were classified as seizure free (78.4% Class I), and six as almost seizure free (8.1% Class II), grouped together as satisfactory seizure control (64 patients, 86.5%). Five patients (6.8%) were categorised in Classes III and IV, respectively. These were grouped as unsatisfactory seizure control (10 patients, 13.5%). Surgical procedures were: 32 amygdalohippocampectomies (AH), 17 partial anterior AH, 15 AH plus polar resection, seven AH plus basal resection, and three AH plus extended temporal lesionectomy. There was no mortality and 2.7% mild permanent morbidity. Seizure relief did neither differ significantly with these approaches, nor with different classes of pathological findings (43 developmental tumours, 12 glial tumours, 10 dysplasias, and nine others). Even operation of dysplasias resulted in 80% satisfactory seizure control. Seizure onset during childhood proved to be a negative predictor for seizure relief (p = 0.020). MRI revealed 73 suspected lesions (98.6%), one dysembryoplastic neuroepithelial tumour was missed, in four cases no structural abnormalities could be confirmed with histopathological exam. Additionally, multifactorial regression revealed the factors "seizure onset after 10 years of age", "presence of complex partial seizures", "absence of a neurological deficit", and a "correlating neuropsychological deficit" as predictive for satisfactory seizure control.

CONCLUSIONS

"Preoperative tailoring" resulting in limit resections has proven to be safe and to provide a very good chance for satisfactory seizure relief in patients with lesional MTLE.