Vascular Injury During Lumbar Disc Surgery: Case Report

A retroperitoneal organ injury-vascular injury or solid organ injury-that occurs during lumbar disc surgery needs to be dealt with adequately, because otherwise it could result in a poor (or, even, fatal) outcome of a "simple" procedure. Vascular injuries require special attention from the neurosurgical side (think of the possibility!) and cooperation between neurosurgeons and abdominal/vascular surgeons. In the presented case of a very obese female patient, a bite injury of the aorta during L3/4 disc surgery led to delayed intra-abdominal hemorrhage, which then required an emergency abdominal operation followed by major thromboembolic complication, and ultimately resulted in amputation of the patient's healthy leg. Pitfalls in intraoperative diagnosis and postoperative care are discussed, along with related medicolegal issues.

Cranial and ventricular size following shunting or endoscopic third ventriculostomy (ETV) in infants with aqueductal stenosis: further insights from the International Infant Hydrocephalus Study (IIHS)

PURPOSE

The craniometrics of head circumference (HC) and ventricular size are part of the clinical assessment of infants with hydrocephalus and are often utilized in conjunction with other clinical and radiological parameters to determine the success of treatment. We aimed to assess the effect of endoscopic third ventriculostomy (ETV) and shunting on craniometric measurements during the follow-up of a cohort of infants with symptomatic triventricular hydrocephalus secondary to aqueductal stenosis.

METHODS

We performed a post hoc analysis of data from the International Infant Hydrocephalus Study (IIHS)-a prospective, multicenter study of infants (< 24 months old) with hydrocephalus from aqueductal stenosis who were treated with either an ETV or shunt. During various stages of a 5-year follow-up period, the following craniometrics were measured: HC, HC centile, HC z-score, and frontal-occipital horn ratio (FOR). Data were compared in an analysis of covariance, adjusting for baseline variables including age at surgery and sex.

RESULTS

Of 158 enrolled patients, 115 underwent an ETV, while 43 received a shunt. Both procedures led to improvements in the mean HC centile position and z-score, a trend which continued until the 5-year assessment point. A similar trend was noted for FOR which was measured at 12 months and 3 years following initial treatment. Although the values were consistently higher for ETV compared with shunt, the differences in HC value, centile, and z-score were not significant. ETV was associated with a significantly higher FOR compared with shunting at 12 months (0.52 vs 0.44; p = 0.002) and 3 years (0.46 vs 0.38; p = 0.03) of follow-up.

CONCLUSION

ETV and shunting led to improvements in HC centile, z-score, and FOR measurements during long-term follow-up of infants with hydrocephalus secondary to aqueductal stenosis. Head size did not significantly differ between the treatment groups during follow-up, however ventricle size was greater in those undergoing ETV when measured at 1 and 3 years following treatment.

The importance of social relationships for brain tumor patients' quality of life: A case for the inclusion of the concept of disclosure in psycho-oncological care

Purpose: Interpersonal factors are of major importance for cancer patients' physical and mental health. Brain tumor patients rank amongst those cancer patients with the highest psychosocial burden. Changes in language, cognition, and personality pose specific risk factors for impeding interpersonal functioning in this patient group. Despite this, role and relevance of social support including both supportive (e.g., emotional support) and detrimental interactions causing distress (e.g., critical remarks) are not well understood. Aims of this study were thus (1) to investigate the association of social support and patients' Health Related Quality of Life (HRQoL) and (2) to assess whether this relationship is mediated by the patients' disclosure behavior.Methods: Seventy-four ambulatory brain tumor patients (mean age 54 years; 58% women) completed the following self-report questionnaires: Illness-specific Social Support Scale (SSUK) for assessment of positive support and detrimental interactions, the Disclosure of Trauma Questionnaire (DTQ) for assessment of patients' disclosure behavior, and the Short-Form Health Survey (SF-8) for assessment of QoL.Findings: Detrimental social interactions were significantly related to patients' mental and physical well-being while positive support was not. Our results support a model in which patients perceiving detrimental social interactions show more difficulties in talking about illness-specific contents in a functional manner. This, in turn, was associated with a lower physical and mental HRQoL.Conclusions: This was the first study in which the close associations of detrimental social interactions, brain tumor patients' dysfunctional disclosure behavior and patients' mental as well as physical well-being were empiricially validated. Thus, dysfunctional disclosure behavior might pose a relevant therapeutic target when offering psycho-oncological support for brain tumor patients and their families.

Linking pre-existing biorepositories for medical research: the PopGen 2.0 Network

The significance of human biorepositories for modern medical research, particularly for comprehensive population-based genetic analyses, is constantly growing. While large and centralized institutions are usually considered best suited to meet the increasing demand for high-quality “biobanks,” most medical research institutions still host rather heterogeneous and fragmented biobanking activities, undertaken by clinical departments with oftentimes rather different scientific scope. Undoubtedly, most clinicians and medical researchers would appreciate infrastructural support in terms of the storage and handling of their biosamples, but they are also likely to expect access to their samples avoiding extensive formal requirements. We report on the establishment of the PopGen 2.0 Network (P2N), an overarching alliance of initially seven biobanks from Northern Germany which adopted a joint but lean governance structure and use-and-access policy for their samples and data. In addition, the members of P2N have pursued an intense collaboration on ethical, legal and social issues and maintain a common IT infrastructure. The implementation of P2N has substantially improved the prospects of biobank-based research at the participating institutions. The network may thus serve as a role model for similar initiatives geared at linking pre-existing biorepositories for the benefit of research quality, efficiency, and transparency.

Cross-cultural adaptation and psychometric properties of the SCOPA-Sleep-German version

Aim of the study was the cross-cultural adaptation and validation of the German version of the Scale for Outcomes in Parkinson's disease-Sleep Scale (SCOPA-Sleep) for assessment of night-time sleep problems (NS) and daytime sleepiness (DS). Eighty-three patients with Parkinson's disease completed the SCOPA-Sleep and a multitude of measures for assessment of validity (e.g., PSQI, ESS). Twenty patients completed the SCOPA-Sleep twice within 2 months for assessment of retest reliability. Sixty-four healthy controls were also included for validity estimation. Internal consistency (Cronbach's alpha) was good with coefficients of .801 and .854 for SCOPA-NS and SCOPA-DS, respectively. Test-retest reliability and inter-rater agreement were excellent. Factor analysis revealed two factors, one for each of the subscales NS and DS. Convergent validity was high with correlations of .797 between SCOPA-NS and PSQI, and .679 between SCOPA-DS and ESS. The German version of the SCOPA-Sleep showed good diagnostic accuracy. Optimal cutoff scores were calculated, resulting in an AUC of .908 for NS and of .959 for DS. The German version of the SCOPA-Sleep is a reliable and valid instrument for assessing NS and DS in patients with Parkinson's disease. As diagnostic accuracy is excellent, this scale can be recommended for routine assessment of both NS and DS in PD combined with other standard measures.

Intended cost reduction in laparoscopic appendectomy by introducing the endoloop: a single center experience

BACKGROUND

Cost reduction measures in medicine are gaining greater importance nowadays, especially in high-volume procedures such as laparoscopic appendectomy (LAE). Currently there are two common methods of dissecting the appendix from the caecal pole: linear stapler and endoloops. The endoloop is the cheaper device but can only be used in uncomplicated cases of appendicitis. Therefore both methods are used in LAE depending on intraoperative findings. The goal of this study was to retrospectively evaluate possible cost reduction due to increased use of endoloop in LAE in our general surgery department of a tertiary referral university hospital.

METHODS

We previously used the stapler for appendix dissection in LAE as our local protocol but introduced the endoloop as standard method in 2015 to reduce intraoperative costs. We conducted a retrospective analysis of patients who underwent LAE between June 2014 and October 2015 in our department. Our purpose is to show the effects on cost reduction during the introductory period adjusting for a potential bias due to the individual learning curve of every surgeon. We estimated costs for LAE by taking into account average device costs and duration of operation (DO) as well as patient outcome.

RESULTS

A total of 177 patients underwent LAE, 73 in 2014 (phase I) and 104 in 2015 (phase II). The median DO was 61 (± 24 SD) min during the entire period, and increased by 14 min from phase I to II (from 51 (±23 SD) min to 65 (±24 SD) min respectively, p < 0.001). The use of endoloops increased from 10% to 55% (p < 0.001). Patients' characteristics and outcomes did not differ significantly. A median saving of 5.9€ per operation was calculated in phase II compared to phase I (p = 0.80).

CONCLUSION

Introducing the endoloop as standard device for LAE leads to a marginal reduction in intraoperative costs without increasing negative outcomes. In our model the cost-reduction achieved by cheaper devices was overcome by increased costs for DO during the initial phase of use of endoloops. A longer follow up might show a more pronounced cost reduction.

Intraoperative Thresholds for Capsular Stimulation Are Reliable for Chronic Pallidal Deep Brain Stimulation in Dystonia

BACKGROUND

The threshold current for inducing muscle contractions by stimulation of pyramidal tract fibres adjacent to the globus pallidus internus (GPi) is, besides microelectrode recordings for the determination of nuclear boundaries, currently the only neurophysiological marker for intraoperative refinement of the anatomically planned target point for pallidal deep brain stimulation (GPi-DBS) in dystonia.

OBJECTIVES

To determine the relationship between intraoperative thresholds for muscle contractions under general anaesthesia and postoperative thresholds in GPi-DBS.

METHODS

Intraoperatively, current amplitude thresholds (120 µs, 130 Hz) were determined in 6 dystonic patients under general anaesthesia (through the uninsulated tip of the microelectrode guide tube). Postoperative localization of chronic stimulation electrodes by MRI and image fusion with the stereotactic planning determined the stimulation contact for comparing thresholds with intraoperative values.

RESULTS

Current thresholds were 3.3 ± 0.8 mA intraoperatively (follow-up 0, FU0; n = 12), 2.9 ± 1.2 mA within 1 week after surgery (FU1; n = 12), and 3.5 ± 1.6 mA after 6-17 months (FU2; n = 8). FU0 and FU1 differed by trend, and FU1 and FU2 were significantly different (Friedman test, p = 0.0048; post hoc Dunn multiple comparison test, p < 0.05). FU0 and FU2 were not different.

DISCUSSION

The threshold amplitude to induce tonic muscular contractions may constitute a valid approach of functionally refining the anatomically guided electrode placement in GPi-DBS for dystonia, because intraoperative values are predictive for postoperative thresholds with the chronically implanted neurostimulation system.

"Inverse signaling" of the transmembrane chemokine CXCL16 contributes to proliferative and anti-apoptotic effects in cultured human meningioma cells

Background

Chemokines and their receptors play a decisive role in tumor progression and metastasis. We recently found a new signaling mechanism in malignant glioma cells mediated by transmembrane chemokines that we termed “inverse signaling”. According to this hypothesis, soluble (s)-CXCL16 binds to the surface-expressed transmembrane (tm) -CXCL16, and induces signaling and different biological effects in the stimulated cells, so that the transmembrane ligand itself acts as a receptor for its soluble counterpart. Now, we hypothesized that “inverse signaling” via tm-CXCL16 might also take place in meningiomas, a completely different, benign tumor entity.

Methods

We used quantitative reverse-transcription polymerase chain reaction, immunocytochemistry and western blot to detect CXCL16 and CXCR6 in human meningioma cells isolated from 28 human meningiomas. Subsequently, we stimulated cultured human tm-CXCL16-positive, CXCR6-negative meningioma cells with recombinant s-CXCL16 and analyzed binding, signaling and biological effects using RNAi silencing to verify specificity.

Results

In fact, cultured human meningioma cells considerably express CXCL16, but substantially lack CXCR6, the only known CXCL16 receptor. These receptor-negative cells could bind s-CXCL16, and responded to s-CXCL16 application with activation of the intracellular kinases ERK1/2 und Akt. As a consequence, we observed increased proliferation and rescue of apoptosis of cultured meningioma cells. Since binding and signaling were abolished by siRNA silencing, we concluded that tm-CXCL16 specifically acts as a receptor for s-CXCL16 also in human meningioma cells.

Conclusion

These findings underline our recent report on the mechanism of inverse signaling as a broad biological process also observable in more benign tumor cells and contributing to tumor progression.

Stem cell markers in glioma progression and recurrence

Aggressive cancer cells show histological similarities to embryonic stem cells. As differentiated cells can re-acquire pluripotency and self-renewal by transfection with the transcription factors OCT4, SOX2, KLF4 and MYC, with Nanog as readout for success, we comprehensively investigated their occurrence and frequency in human astrocytomas of different malignancy grades, primary and matched recurrent glioblastomas, short- and long-term glioblastoma cultures and glioma cell lines. Among astrocytomas, mRNA expression of OCT4, MYC and (less robust) KLF4 increased with malignancy, while in recurrent glioblastomas MYC expression slightly decreased. Correlation analysis revealed distinct positive correlation between distinct stem cell markers, and this effect was most prominent in the recurrent glioblastoma cohort. In situ, embryonic stem cell factors were found also in more differentiated tumor regions. Respective cells were rarely actively proliferating and showed single or combined expression signatures, which, at least in parts, corresponded to observed positive correlations of mRNA expression. However, a 'master-marker' defining the complete glioma stem cell subset could not be confirmed. In glioma cell lines, long- and short-term cultures, embryonic markers were detected at comparable levels. Upon exposure to temozolomide, increased expression of KLF4 (and lesser Nanog and OCT4) was observed. Experimental intrinsic overexpression of SOX2, KLF4 or OCT4 did not affect the other stem cell factors. The embryonic stem cell factors comprehensively investigated in this project can control self-renewal and pluripotency, and therefore tumorigenicity. They should be considered for the development of future diagnostic and therapeutic strategies.

Differential expression of CXCR4 and CXCR7 with various stem cell markers in paired human primary and recurrent glioblastomas

The chemokine CXCL12 (also termed SDF-1, stromal cell-derived factor-1) and its receptors CXCR4 and CXCR7 are known to play a pivotal role in tumor progression including glioblastomas (GBM). Previous investigations focused on the expression and functional roles of CXCR4 and CXCR7 in different GBM cell subpopulations, but comparative analysis in matched primary versus recurrent GBM samples are still lacking. Thus, here we investigated the expression of CXCR4 and CXCR7 on mRNA and protein level using matched primary and recurrent GBM pairs. Additionally, as GBM CXCR4-positive stem-like cells are supposed to give rise to recurrence, we compared the expression of both receptors in primary and recurrent GBM cells expressing either neural (MUSASHI-1) or embryonic stem cell markers (KLF-4, OCT-4, SOX-2, NANOG). We were able to show that both CXCR4 and CXCR7 were expressed at considerable mRNA and protein levels. CXCR7 was downregulated in relapse cases, and different groups regarding CXCR4/CXCR7 expression differences between primary and recurrent samples could be distinguished. A co-expression of both receptors was rare. In line with this, CXCR4 was co-expressed with all investigated neural and embryonic stem cell markers in both primary and recurrent tissues, whereas CXCR7 was mostly found on stem cell marker-negative cells, but was co-expressed with KLF-4 on a distinct GBM cell subpopulation. These results point to an individual role of CXCR4 and CXCR7 in stem cell marker-positive GBM cells in glioma progression and underline the opportunity to develop new therapeutic tools for GBM intervention.

Intracranial Meningiomas: A 30-Year Experience and Literature Review

Intracranial meningiomas are tumors arising from the covering cells of the arachnoid layer of the dura mater or from the intraventricular choroid plexus. While mostly benign tumors, they still represent a major challenge to neurosurgeons and other medical disciplines involved in their diagnostic and therapeutic management. Although this review intends to give some state-of-the-art information from the literature, it is mainly based on personal experiences since more than 30 years caring for more than 1500 meningioma patients and point to a few new strategies to further improve on patient outcome.Diagnostics are based on magnetic resonance imaging which shows the relationship between tumor and surrounding intracranial structures, particularly the brain but also the vasculature and to some extent the cranial nerves. Furthermore, it may suggest the grading of the tumor and is very helpful in the postoperative diagnosis of complications and later follow-up course.Surgery still is the main treatment with the aim to completely remove the tumor; also in cases of recurrence, other additional options include radiotherapy and radiosurgery for incompletely removed or recurrent meningiomas. Postoperative chemotherapy has not been shown to provide substantial benefit to the patient especially in highly malignant meningiomas.All therapy options should be intended to provide the patient with the best possible functional outcome. Patients' perspective is not always equivalent to surgeons' perspectives. Neuropsychological evaluation and additional guidance of patients harboring meningiomas have proven to be important in modern neurosurgical intracranial tumor treatment. Their help beyond neurosurgical care facilitates the patients to lead an independent postoperative life.

A novel simple measure correlates to the outcome in 57 patients with intracerebellar hematomas. Results of a retrospective analysis

BACKGROUND

The incidence of intracerebellar hemorrhages approaches 5-10% of all intracerebral hematomas. The clinical presentation varies from headaches and dizziness to rapid deterioration of consciousness to the point of coma in severe cases. In order to find some concrete criteria that could influence the prognosis of these patients, we performed this retrospective study.

METHODS

We retrospectively analyzed the factors influencing the outcome of 57 patients with intracerebellar hematomas treated in our clinic in the last 7 years. The Glasgow Coma Scale (GCS) on admission, as well as other parameters as hypertension, diabetes mellitus, presence of malign tumors in the medical history, or the intake of anticoagulants were assessed as independent factors influencing the outcome of the patients. On the other hand, various computed tomography parameters on admission were also correlated with the clinical outcome such as, tight posterior fossa (TPF), volume of the hematoma, hydrocephalus, compression of the fourth ventricle, intraventricular bleeding, as well as the ratio of the maximal width of the hematoma in comparison to the width of the PF were taken into consideration.

RESULTS

The results of the study showed that patients with poor GCS on admission had also a poor Glasgow Outcome Score. Interestingly there was a statistically significant correlation between the maximal width of the hematoma in comparison to the width of the PF and the outcome of the patients. It could be also shown that the patients with intraventricular hemorrhage, hydrocephalus, compression of the fourth ventricle over 50% of its maximal width and TPF, had a poor clinical outcome. Moreover, there was a statistically significant correlation of the volume of the hematoma and a poor clinical outcome.

CONCLUSIONS

We introduced as a new factor that is, the cerebellar hemorrhage/PF ratio and found out that the value >35% was associated to an unfavorable outcome.

Epithelial-to-mesenchymal transition in paired human primary and recurrent glioblastomas

Patients with highly malignant glioblastomas have a short median survival time mainly due to aggressive relapses after therapeutic treatment. Beside others, they achieve their progressive character via epithelial-to-mesenchymal transition (EMT). However, comprehensive investigations on EMT in paired primary-recurrent glioblastoma pairs are presently not available. Thus, in our present study we examined the expression profile of different EMT-markers in 17 matched primary and recurrent glioblastomas by qPCR and double-immunofluorescence stainings to identify EMT marker expressing cell types. Additionally, we analyzed the influence of temozolomide on EMT marker expression in vitro. In comparison to primary tumors, expression of β-catenin (p<0.05), Snail1 (p<0.05), Snail2/Slug (p<0.05), biglycan (p<0.05) and Twist1 (p<0.01) was downregulated in recurrence whereas L1CAM showed upregulation (p<0.05; qPCR). Expression of desmoplakin, vimentin, fibronectin and TGF-β1 with its receptors TGF-βR1 and TGF-βR2 was almost unchanged. Comparing each individual pair, five different 'EMT groups' within our glioblastoma collective were identified according to the regulation of mRNA expression of GFAP, desmoplakin, Snail1, Snail2, Twist1 and vimentin. Additionally, double-stainings of EMT markers in combination with cell specific markers (glial fibrillary acidic protein, CD11b, von Willebrand factor) revealed that EMT markers were expressed in a complex pattern with all three cellular types as possible sources. Temozolomide treatment significantly induced mRNA expression of nearly all investigated EMT markers in T98G glioma cells. Thus, EMT seems to be involved in glioma progression in a complex way requiring an individualized analysis, and is influenced by commonly used therapeutic options in glioma therapy.

Impact of chemokines on the properties of spinal cord-derived neural progenitor cells in a rat spinal cord lesion model

The existence of endogenous neural progenitor cells (NPCs) in the adult spinal cord (sc) provides the potential for tailored repair therapies after spinal cord injury (SCI). This study investigates the impact of inflammatory mediators on properties of NPC cultures derived from adult rats after SCI. The Infinite Horizon impactor was used to apply 200-kdyn thoracic sc lesions in adult rats. Control groups received laminectomies to equivalent sc regions. Thoracic sc segments were taken for neurosphere cell cultures. Cell proliferation was found to be significantly higher in lesion groups. Neurosphere-derived cells differentiated into neurons, oligodendroglia, and astroglia. Lesion cultures exhibited significantly higher amounts of glial fibrillary acidic protein (GFAP) mRNA (P < 0.0005) and β-III-tubulin mRNA (P < 0.05) compared with sham animals. Neurospheres from different treatment groups exhibited the same amounts of tumor necrosis factor-α, interleukin (IL)-1β, and IL-6 mRNA. C-C chemokine receptor (CCR) expression on neurospheres was examined by real-time RT-PCR. CCR1 was expressed most consistently in mRNA levels in neurospheres from both treatment groups. After cell differentiation, CCR1 mRNA amounts decreased. CCR1 was detectable by immunohistochemistry in neurospheres and differentiated cells of both groups. Application of CCL3 during differentiation cycles led to significantly higher GFAP mRNA amounts in sham animals compared with CCL3-free cultures; in contrast, CCL3 had no impact on cell differentiation in the lesion group. In conclusion, impact SCI alters differentiation tendencies and proliferation rates of adult-derived sc NPCs. Thereby, CCR1/CCL3 promotes specifically astroglial differentiation of NPCs, which provides a potential target for future neurorestorative approaches.

Expression of DNA mismatch repair proteins MLH1, MSH2, and MSH6 in recurrent glioblastoma

OBJECTIVES

Methylated O6-methylguanin-DNA-methytransferase (MGMT) promoter methylation is associated with survival in patients with glioblastoma. Current evidence suggests that further mismatch repair genes play a pivotal role in the tumor response to treatment. Candidate genes are MLH1, MSH2, and MSH6. Formerly, we found evidence of prognostic impact of MLH1 and MSH6 immunohistochemical expression in a small series of patients with initial glioblastoma.

METHODS

Two hundred and eleven patients were included who underwent macroscopically total removal of primary glioblastoma and at least one re-craniotomy for recurrence. Immunohistochemical staining was performed on paraffin-embedded specimens of initial tumors with specific antibodies against MLH1, MSH2, and MSH6. RESULTS were compared to the Ki67 proliferation index and patient survival. Additionally, fresh frozen samples from 16 paired initial and recurrent specimens were examined using real-time reverse transcription polymerase chain reaction (RT-PCR) with specific primers against MLH1, MSH2, and MSH6. RESULTS were compared to MGMT status and survival.

RESULTS

(1) Immunohistochemical expression of MSH6 was significantly associated with the Ki67 proliferation index (P<0.001) but not with survival. (2) PCR revealed two patients with increasing expression of MLH1, MLH2, and MSH6 over treatment combined with lacking MGMT methylation. In another two patients, decreased MLH1, MSH2, and MSH6 expression was observed in combination with MGMT promoter methylation.

DISCUSSION

Our data indicate that there may be glioblastoma patient subgroups characterized by MMR-expression changes beyond MGMT promoter methylation. The immunohistochemical expression of MLH1, MSH2, and MSH6 in initial glioblastoma is not associated with patient survival.

Chemokine expression profile of freshly isolated human glioblastoma-associated macrophages/microglia

Several studies have substantiated the hypothesis that tumor progression is not only driven by the tumor cells themselves but also by their interaction with intrinsic and surrounding stromal cells. Tumor-associated macrophages and microglial cells (TAMs) represent one major stromal cell component of glioblastomas. Additionally, in many gliomas, chemokines are highly expressed and some chemokines were already linked to settlement of TAMs in tumors. However, although chemoattraction mechanisms mediated by chemokines and their receptors are well documented, information on their expression and role in TAMs, particularly in patients, is limited. Therefore, we investigated the transcription of the chemokine-receptor combinations CXCL12-CXCR4-CXCR7, CXCL16-CXCR6 and CX3CL1-CX3CR1 in freshly isolated TAMs from 20 human glioblastomas in relation to in vitro polarized M1- and M2-macrophages. We demonstrated that TAMs express both M1- and M2-markers. Compared to in vitro polarized macrophages, the M1-marker interleukin (IL)-6 was similarly expressed, whereas IL-1β and tumor necrosis factor (TNF)-α were found at lower levels. The M2-marker IL-10 was comparably expressed, while CD163 and transforming growth factor (TGF)-β were detected with one tenth lower intensities in TAMs. All investigated chemokines/receptors were transcribed at moderate to high levels in TAMs as well as in vitro polarized macrophages. However, CX3CR1 was markedly higher and CXCR7 was somewhat higher expressed in TAMs, whereas M2-macrophages were characterized by the highest CXCL12 and a moderate CX3CL1 expression. Collectively, TAMs share properties of M1- and M2-macrophages and show a considerably higher expression of the chemokine receptors CXCR7 and CX3CR1.

Motor outcome of dystonic camptocormia treated with pallidal neurostimulation

BACKGROUND

Deep brain stimulation of the internal pallidum (GPi-DBS) is effective for various types of drug-refractory primary dystonias. Rare clinical forms as dystonic camptocormia may profit but available data are scarce.

METHODS

We here report on a retrospective clinical assessment of three patients with primary dystonic camptocormia treated with GPi-DBS.

RESULTS

All three patients showed marked response to bilateral GPi-DBS within days to weeks after surgery which was preserved in the long-term (38-45 months after implantation: mean improvement 82% as rated on the Burke Fahn Marsden Dystonia Rating Scale, 89% in the subitem "trunk"). Two patients developed mild stimulation induced speech problems (stuttering or dysarthria) which resolved with reprogramming or were acceptable in return for the control of dystonic symptoms.

CONCLUSIONS

The diagnosis and treatment of camptocormia will continue to require expert knowledge in movement and neuromuscular disorders, but DBS may expand treatment options in this difficult patient population.

Clinical and Histological Features of Multiple Meningiomas Compared with Solitary Meningiomas

Between 1991 and 2002, 456 patients with an intracranial meningioma were treated. Thirty-nine of these had more than one meningioma (8.6%). The mean age was 58 years (27-85 years). Sex distribution was 8.8:1 (35 female, four male). There was no associated spinal meningioma. No patient had neurofibromatosis. In 19 patients all meningiomas were removed. Twelve showed the same histology, seven had different histological features. In the remaining 20 patients only the symptomatic meningioma was removed. Recurrences occurred in 11 patients (28.2%). Six patients died during follow-up. Multiple meningiomas have their own clinical features. Besides a high female preponderance, PR expression was stronger in multiple meningiomas than in solitary meningiomas while p53 status and MIB-1 LI were similar between the two groups. Progesterone receptor, p53 status and MIB-1 LI were valuable markers for predicting a patient's outcome in multiple meningiomas. The number of meningiomas is growing in patients with recurrent meningiomas.

MGMT promoter methylation status and prognosis of patients with primary or recurrent glioblastoma treated with carmustine wafers

The prognostic role of O(6)-methylguanine-DNA methyltransferase (MGMT) promoter methylation in glioblastoma patients treated with carmustine (BCNU) wafer implantation is unclear. Here, we report on a retrospective study of 47 patients with either newly diagnosed (30 patients) or recurrent (17 patients) glioblastoma (WHO grade IV) treated with BCNU (bis-chloroethylnitrosourea) wafers. Thirteen of the newly diagnosed patients received local BCNU and irradiation only (first-line BCNU), while 17 patients additionally received concomitant and adjuvant temozolomide (TMZ) radiochemotherapy (first-line BCNU + TMZ). Of the 17 patients treated for recurrent glioblastoma (second-line BCNU), 16 had received radiotherapy with concomitant and adjuvant TMZ as an initial treatment. Median overall survival (OS) did not significantly differ between 19 patients with MGMT promoter methylated tumors when compared to 28 patients with unmethylated tumors (18.9 vs 15.0 months; p = 0.1054). In the first-line BCNU + TMZ group, MGMT promoter methylation was associated with longer OS (21.0 vs 11.1 months, p = 0.0127), while no significant survival differences were detected in the other two subgroups. Progression-free survival did not significantly differ between patients with and without MGMT promoter methylated tumors in the entire patient cohort or any of the three subgroups. The first-line BCNU + TMZ group showed no significant difference in OS when compared to the first-line BCNU group (18.9 vs 14.7 months), but tended to have more therapy-related adverse effects (53% vs 24%, p = 0.105). In summary, MGMT promoter methylation showed a non-significant trend toward longer survival in our patient cohort. The combination of TMZ radiochemotherapy with local delivery of BCNU did not provide a significant survival benefit compared to local BCNU alone, but was associated with a higher rate of adverse effects. Owing to the small number of patients investigated, however, these findings would need to be corroborated in larger patient cohorts.

Expression of the chemokines CXCL12 and CX3CL1 and their receptors in human nerve sheath tumors

Peripheral nerve sheath tumors are in most cases slowly growing neoplasms that can be adequately cured by surgical resection. However, facing the risk of a neurosurgical intervention and the trend of multiple relapses of nerve sheath tumors the development of additional therapy strategies seems to be favourable, and therefore substantiated knowledge of molecular and cellular mechanisms in nerve sheath tumors should be achieved. Here, we firstly describe the expression of the chemokines CXCL12 (SDF-1) and CX3CL1 (fractalkine) and their respective receptors CXCR4, CXCR7 and CX3CR1 in different entities of human nerve sheath tumors and normal control tissues. Both ligands and their receptors are expressed in high to moderate levels on mRNA and protein level in benign and malignant nerve sheath tumors. While CXCL12 was mainly found in schwannoma cells (S100⁺) in situ, its receptor CXCR4 is also partly found on CD11b-positive macrophages / microglia and its alternative receptor CXCR7 is also expressed by endothelial cells and macrophages. CX3CL1 is expressed by parts of the schwannoma and endothelial cells, whereas its receptor CX3CR1 is expressed by nearly all tumor cells and macrophages, but not by endothelial cells. Taken together, we could show the presence of CXCL12 and CX3CL1 and their respective receptors in benign and malignant human nerve sheath tumors. Further investigations may show their functional role in health and disease.

Growth pattern of tumor recurrence following bis-chloroethylnitrosourea (BCNU) wafer implantation in malignant glioma

Bis-chloroethylnitrosourea (BCNU; Gliadel, Eisai, Tokyo, Japan) is the only therapeutic agent for local chemotherapy of malignant gliomas approved by the US Food and Drug Administration and the European Medicines Agency. In a small patient cohort, it has previously been shown that glioblastomas recur locally despite treatment with BCNU. This raises concern about local treatment with BCNU as a stand-alone measure. The goal of this study was to analyze the growth pattern of tumor recurrence in a larger patient group: 41 patients were included in this study. Tumor recurrences were morphologically categorized as: local, diffuse, distant or multilocular. Thirty-three of the tumors (80%) that recurred were local or diffuse. These results show that BCNU implantation does not provide lasting local tumor control. Our data support the need to incorporate BCNU in to multimodal therapy schemes. The improved survival rates of patients who receive concomitant local and systemic adjuvant treatment support using local therapy to bridge the therapy-free interval of the initial postoperative phase.

The transmembrane chemokines CXCL16 and CX3CL1 and their receptors are expressed in human meningiomas

Meningiomas are common slowly growing benign tumors, however, anaplastic meningiomas have an aggressive biological and clinical behavior associated with high rates of recurrence and unfavorable prognosis. Since the molecular mechanisms involved in progression of meningiomas are not yet fully understood and recent investigations have suggested a possible role of chemokines in tumor biology, the aim of the study was to investigate the expression of CX3CL1/CX3CR1 and CXCL16/CXCR6 on mRNA and protein level in human meningiomas. Quantitative reverse-transcription polymerase chain reaction, immunohistochemistry and double immuno-staining techniques were used for the investigations. We showed that mRNA and protein expression of the chemokine/receptor pairs CX3CL1/CX3CR1 and CXCL16/CXCR6 were detectable in human meningioma samples. Double immunostaining revealed that the chemokines/receptors were predominantly expressed in the tumor cells themselves, in infiltrating microglia cells/macrophages and endothelial cells of blood vessels. Nevertheless, not all cells of different kinds were positive for different chemokine/receptors. Of note, in comparison to more benign meningioma samples, CX3CR1 and CXCL16 were found to be expressed at lower levels in anaplastic variants. Moreover, a positive correlation between expression levels of ligands and corresponding receptors could be observed for some malignancy grades. Taken together, these results showed that chemokines and their receptors are involved in the pathogenesis of human meningiomas. Our results provide an interesting basis for further investigations that should be performed to characterize the functional roles of chemokines and their receptors in human meningiomas, and also enhance future therapeutic design.

The transcription factor Forkhead box P3 (FoxP3) is expressed in glioma cells and associated with increased apoptosis

The forkhead transcription factor FoxP3 is critically involved in the development and function of regulatory T cells (Tregs) that populate tumors and are considered as powerful parts of their immune evasion. However, also tumor cells are reported to express FoxP3. Since gliomas are particularly immunosuppressive tumors, we investigated the occurrence and possible functions of FoxP3 in these malignant cells. By quantitative RT-PCR, immunohistochemistry and FACS analysis, we detected FoxP3 in glioma cells in situ and in vitro. After exposure of glioma cell lines to chemotherapeutics, expression of FoxP3 was significantly enhanced, and it was dislocated from more nuclear to perinuclear localization. Overexpression of FoxP3 in glioma cell lines considerably favored apoptotic damage of nuclei, DNA fragmentation, increased cleavage of the pro-apoptotic enzyme poly(ADP-ribose) polymerase (PARP) and basal activities of effector caspases-3/7. In FoxP3-transfected cells, apoptotic stimuli like Camptothecin, Temozolomide or tumor necrosis factor-α synergistically enhanced caspases-3/7-activities over controls. Taking together, FoxP3 occurs in glioma cells, is induced by chemotherapeutics, and its expression is correlated with increased apoptosis of glioma cells, especially when propagated by apoptotic stimuli. Thus, FoxP3 is a novel pro-apoptotic transcription factor in gliomas that is critically involved in the action of apoptotic agents.

Affective state and cognitive functioning in patients with intracranial tumors: validity of the neuropsychological baseline assessment

OBJECTIVES

The aim of this paper is to investigate the relationship between the affective and cognitive states of neurooncological patients prior to the neurosurgical treatment to assess associations between distress levels and neuropsychological test performance in this sample and setting.

METHODS

The prospective study population consists of 172 patients. Patients were studied preoperatively with a comprehensive test battery consisting of a variety of affective and cognitive measures. Psychological instruments included the Hospital Anxiety and Depression Scale, the Amsterdam Preoperative Anxiety and Information Scale, and the Acute Stress Disorder Scale.

RESULTS

Factor analysis revealed two factors representing subjective affective functioning: whereas one reflects the patients' more general emotional state (Hospital Anxiety and Depression Scale, Acute Stress Disorder Scale), the second reflects anxiety specifically related to the neurosurgical procedure (Amsterdam Preoperative Anxiety and Information Scale). After age and education have been accounted for via linear regression analyses, affect did not contribute to cognitive performance in any of the cognitive domains in the whole patient sample. However, in patients with extreme levels of psychiatric morbidity, there was evidence for distinct cognitive morbidity consistent with previous research.

CONCLUSIONS

Our results suggest that, for a large variety of widely used neuropsychological measures and for most neurooncological patients, the preoperative neuropsychological baseline assessment can be considered valid and dependable. In patients with extreme levels of distress, however, distinct cognitive domains might be differentially affected.

The atypical subthalamic nucleus--an anatomical variant relevant for stereotactic targeting

BACKGROUND

The improvement of PD motor symptoms by DBS of the STN depends on exact targeting.

METHODS

A combination of MRI and multitrajectory microrecordings was used for localization of the STN in a group of 228 consecutive PD patients.

RESULTS

In 1% of our cases, the STN was consistently shifted in the anterior (3.3 ± 0.8mm) and medial (3.0 ± 0.9 mm) direction within the target plane, compared to controls. Adjustment of the original target coordinates after intraoperative reevaluation of the MRI and confirmation by typical subthalamic neuronal recordings along the deviant trajectory allowed the implantation of clinically effective electrodes in all cases. The relative improvement of the motor UPDRS at 6-months follow-up in patients with an atypical and typical STN was comparable.

CONCLUSION

An atypical position of the STN does not need to complicate DBS surgery, if detected by a combination of MRI-based targeting and electrophysiological guidance.

Glioblastoma: clinical characteristics, prognostic factors and survival in 492 patients

OBJECTIVE

Glioblastoma is the most common and most malignant primary brain tumor in adults. The only overall accepted independent prognostic factors are patient age and performance. We present a large single institution patient series examined for prognostic factors using uni- and multivariate survival analysis.

METHODS

492 patients were included who underwent craniotomy for newly diagnosed glioblastoma WHO grade IV between 1990 and 2007 at our department. The association to patient survival was estimated using log-rank test for univariate analysis and cox regression method for multivariate analysis.

RESULTS

Median patient age was 62 years (mean: 60.4 years, range: 22-93 years), the male: female ratio was 1.26:1. Primary genesis was found in 91.0% of cases. A multifocal tumor was present in 110 cases (22.4%). The median pre- and post-operative Karnofsky Performance Score was 70. Total tumor resection was performed in 288 cases (58.5%), subtotal removal in 134 cases (27.2%). The following parameters were significantly associated with survival in univariate analysis: age, performance, primary genesis, multifocal tumor, neurological deficit, neuropsychological findings, seizures, incidental finding, total or subtotal resection, radiotherapy, chemotherapy, combined radio-/chemotherapy with temozolomide, re-craniotomy, second tumor in patient history. The following parameters were significantly associated with survival in multivariate analysis: age, performance, multifocal tumor, total or subtotal resection, radiotherapy, chemotherapy, combined radio-/chemotherapy with temozolomide.

CONCLUSION

In addition to patient age and performance, we identified multiple lesions and resection status as independent prognostic factors. Radiotherapy, chemotherapy and combined radio-/chemotherapy with temozolomide were significantly associated with prolonged survival.

Deep brain stimulation of the posterior hypothalamic area in intractable short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT)

Background: SUNCT (short-lasting unilateral neuralgiform headache with conjunctival injection and tearing) is a rare syndrome characterized by the sudden onset of excruciating unilateral periorbital pain that is accompanied by conjunctival injection and lacrimation or further autonomic signs. Similar to patients with chronic cluster headache, Leone and Lyons showed a beneficial effect of deep brain stimulation of the posterior hypothalamic region in two patients with a chronic SUNCT.

Case: Here, we present the case of a man with a chronic SUNCT responding to deep brain stimulation of the posterior hypothalamic area.

Conclusion: This case supports the idea of a central origin of SUNCT and shows that deep brain stimulation of the hypothalamic region can be effective in the treatment of the chronic form of this rare disorder.

SP100 reduces malignancy of human glioma cells

The nuclear autoantigen SP100 (speckled protein 100) is reported to control cellular gene expression, cell growth and differentiation. To investigate its relevance in brain tumors, we investigated SP100 expression and function in human glioblastomas and meningiomas. SP100 was expressed in both tumors at the mRNA and protein levels in situ and in vitro, however, expression in meningioma samples and meningioma cells exceeded that in glioblastoma samples and cultivated cells significantly. Moreover, whereas nearly all meningioma cells were SP100-immunopositive, only part of the glioblastoma cells were SP100 stainable. In vitro, SP100 was upregulated by interferon-α and -γ in both malignant cell types. To study its functional role, SP100 was overexpressed in glioblastoma cells. This SP100 overexpression reduced considerably the glioblastoma cell proliferation and migration to fetal calf serum. We conclude that SP100 expression reduces malignancy of brain tumors. Since meningiomas show a generally higher SP100 expression, this may be one of the factors explaining their lower malignancy compared to glioblastomas.

Distress in patients with newly diagnosed brain tumours

OBJECTIVE

Patients with intracranial tumours often suffer from clinically relevant psychological distress. However, levels of distress and contributing factors have not been systematically evaluated for the early course of the disease. Using the National Comprehensive Cancer Network's Distress Thermometer (DT), we evaluated the extent and sources of distress within a population of patients with intracranial neoplasms.

METHODS

One hundred and fifty-nine patients were included who underwent craniotomy for newly diagnosed intracranial tumours at our department. All patients completed the DT questionnaire, a single-item 11-point visual analogue scale measuring psychological distress. The appendant problem list (PL) consists of 40 items representing problems commonly experienced by cancer patients. Patients were asked to mark any experienced sources of distress.

RESULTS

Percentage of patients suffering from relevant distress was 48.4% (cut-off ≥6). DT-scores were significantly associated with depression and anxiety as well as reported number of concerns. On average, patients reported 6.9 sources of cancer-related distress. Objective medical data (e.g. tumour stage) as well as sociodemographic data (e.g. gender, IQ) were not associated with psychological distress at this early phase.

CONCLUSIONS

Prevalence of elevated distress is high shortly after primary neurosurgical treatment in patients with intracranial tumours and cannot be predicted by objective data. As a consequence, sources of distress can and should be routinely assessed and targeted in these individuals in this particular period. Further studies are needed to help to identify patients who are at risk of suffering from long-term emotional distress in order to enable targeted psychosocial intervention.

Space-occupying cyst development in the resection cavity of malignant gliomas following Gliadel® implantation--incidence, therapeutic strategies, and outcome

Gliadel® (Eisai Inc., Woodcliff Lake, NJ, USA) is the only therapeutic agent approved by the Food and Drug Administration and the European Medicines Agency for local chemotherapy of malignant gliomas. With increasing use of this treatment, characteristic side effects have become evident. While most side effects can be managed conservatively, cyst formation requires further intervention. From 2004 to 2009 at our institution 88 patients with malignant gliomas were treated with Gliadel®. Ten patients (11%) developed a space-occupying cyst in the resection cavity, seven of which caused clinical symptoms of mass effect that was most prominent 2 weeks after Gliadel® implantation (median=16, range=9-30). Despite dexamethasone treatment symptoms progressed, necessitating various surgical interventions. In four patients the cysts were drained percutaneously through a burrhole using a 19-gauge needle. If puncture was not possible (three patients) or not sufficient (two patients), an Ommaya reservoir was implanted for repetitive drainage. In two patients this treatment was combined with open decompression of the cyst. On average, cysts were drained three times. Eventually the symptoms subsided, corresponding to shrinkage of the cysts as shown on follow-up imaging. We describe a serious side effect of local chemotherapy, which may cause rapid clinical deterioration and require direct intervention. While reservoir implantation apparently represents a more elegant treatment option, our experience shows that draining the cyst, even only a few times, sufficiently ameliorates the symptoms and subsequently reverses and halts further cyst enlargement.

Resistant vasospasm in subarachnoid hemorrhage treated with continuous intraarterial nimodipine infusion

Cerebral vasospasm complicating aneurysmal subarachnoid hemorrhage is a well-known medical entity. The delayed ischemic neurological deficits (DIND) as a result of vasospasm remain the main cause of morbidity among patients who manage to survive this severe disease pattern. When the traditional treatment options, either medical or interventional, fail to reverse vasospasm, continuous intraarterial infusion of nimodipine through catheters directly into the spastic arteries presents a promising treatment modality. Of 73 patients with aneurysmal subarachnoid hemorrhage between 2008 and 2009, a total of 27 had Hunt and Hess grades of 4 and 5. Fifteen percent of them showed refractory vasospasms and were treated with continuous nimodipine infusion via catheters in both internal carotid arteries. We present the method's indications and possible complications.

Measurement of psychological distress in patients with intracranial tumours: the NCCN distress thermometer

Identification of patients suffering from elevated psychosocial distress, the sources of the distress, and the necessary treatment of the distress can be rather difficult within the neurosurgical setting (e.g., lack of time, cognitive or aphasic disorders of the patients). The distress thermometer (DT) is a single-item rapid distress screening tool by use of which these difficulties can be minimized. The objective of this study was to determine the optimum DT cut-off score that would identify significant distress in patients with intracranial tumours thus validating its use in the neurosurgical setting. In all, 150 patients were tested either during in-patient stay or during a follow-up examination before and after the neurosurgical removal of a primary intracranial neoplasm. Patients were administered the DT with the hospital anxiety and depression scale (HADS), the gold standard against which the DT was compared. The area under the receiver operating characteristics curve (ROC) was ≥0.82. Thus, the ability of the DT to correctly identify patients as significantly distressed was excellent. The DT ranges from 0 to 10. Its optimum cut-off score for identifying distressed patients was at or above 6 (sensitivity ≥ 88%; specificity ≥ 53%). The DT is a valid and practicable screening instrument for assessment of levels and sources of distress in patients with intracranial tumours in the neurosurgical setting.

A new tool for the navigated placement of intracerebral chemotherapy catheters

OBJECTIVE

The aim of this report is to illustrate a method for the precise placement of chemotherapeutic delivery catheters with the aid of computer-assisted navigation systems.

MATERIALS AND METHODS

We have developed a cannula which can be referenced to our navigation system (BrainLab (®)) to advance and position catheters. The cannula has a length of 10 cm. In the case of a ventricular puncture, CSF will drain through holes at the tip and a side port of the cannula to caution the surgeon. The cannula is fixed to the BrainLab (®) adapter ML and navigated with a BrainLab (®) vector vision (®) system. Using the puncture software, the placement is planned and executed. After placing the cannula as planned, the mandrin is removed and the primed catheter moved forward. When resistance is felt the cannula is withdrawn over the catheter. Further catheters can be placed similarly.

RESULTS

Initial phantom tests showed a good target accuracy. Clinically we have used the cannula in 7 cases with good accuracy.

CONCLUSION

This newly designed tool is easy to handle and well integrated into the navigation system. It provides the means to place catheters precisely to the planned position. Potentially it can be combined with every navigation system using adaptable reference systems.

Surgical treatment for brain metastases: Prognostic factors and survival in 309 patients with regard to patient age

Brain metastases are the most common intracranial tumors. Overall, the only accepted prognostic factors are patient age and performance status. However, several other factors are considered before surgery. We performed a retrospective analysis of 309 patients who underwent surgical resection of newly diagnosed brain metastases between 1994 and 2004. Univariate survival analysis revealed age, performance status, extracranial metastases, complete resection, radiotherapy and re-craniotomy as prognostic indicators. Multivariate analysis determined that patient age, performance status, extracranial metastases, radiotherapy and re-craniotomy are independent factors of prolonged survival. We statistically estimated the age threshold separating patients with favorable outcomes from those with unfavorable prognoses. Using the Kaplan-Meier analysis this threshold can be set at 65 years. Multivariate analysis of patients >65 years revealed the presence of co-morbidities, the number of brain metastases, post-operative performance status and radiotherapy as independent prognostic factors.