Hemispheric infiltrative grade II gliomas in adults: association of residual tumour volume and extent of tumour resection with malignant transformation

OBJECTIVES

Evaluation of the impact of surgical treatment on malignant transformation (MT) of adult supratentorial infiltrative grade II gliomas (G2G) in a series of chemotherapy and radiotherapy-naïve patients.

BACKGROUND

Despite G2G are slow-growing tumours, they typically undergo MT with a subsequent fatal disease course. An extensive resection alone likely changes their biological behaviour and defers MT; however, this impact is not unequivocally confirmed.

METHODS

Thirty-eight chemotherapy and radiotherapy-naïve adult patients operated from 2005 till 2014 for a G2G were investigated. Based on postoperative magnetic resonance imaging (MRI) and/or positron emission tomography follow-up (FU) scans, the patients were classified as "transformers" (15 patients in whom MT occurred during the FU-period) and "non-transformers" (23 patients).

RESULTS

The follow-up period of "non-transformers" was longer (p <0.0001). After adjustment for known risk factors - age, male sex, astrocytoma histology, preoperative tumour volume, preoperative contrast enhancement and positive isocitrate dehydrogenase 1 gene mutation status - a larger log postoperative tumour volume (p=0.031) and a smaller extent of resection (p=0.0086) were associated with a shorter MT-free survival.

CONCLUSION

In our series, less extensive resections were associated with a shorter time to MT. Our data support an adoption of techniques enabling extensive G2G resections, such as intraoperative imaging and awake resections, into everyday routine (Tab. 1, Fig. 2, Ref. 40).

Low serum vitamin D levels are associated with a low percentage of TREM-2+ monocytes in low-grade gliomas and poorer overall survival in patients with high-grade gliomas

INTRODUCTION

Anti-inflammatory effect of vitamin D (VD) could be beneficial in improving the survival of glioma patients. The aim of our study was to analyse the serum levels of vitamin D in glioma patients and to find an association with the prognosis of glioma patients and other investigated parameters.

MATERIAL AND METHODS

The study included 63 patients with gliomas. Percentage of CD14+ monocytes, TREM-1+ and TREM-2+ monocytes were determined by flow cytometry, serum levels of 25(OH)D were evaluated by electrochemiluminescent binding test.

RESULTS

Six patients out of 63 had normal levels of VD. A significant difference in the overall survival (OS) in the patients with severe VD deficiency, VD deficiency and insufficiency in grade IV was found. In grade II and III, the levels of vitamin D positively correlated with the percentage of TREM-2+ monocytes, and in grade II also a negative correlation of VD with TREM-1/TREM-2 ratio was observed.

CONCLUSION

Levels of VD could influence the prognosis of patients with high-grade gliomas. Serum level of 25(OH)D in low-grade gliomas positively correlated with the percentage of anti-inflammatory acting TREM-2+ monocytes and negatively with TREM-1/TREM-2 ratio. This could be protective against the progression to high-grade glioma, because TREM-2 is associated with protective functions such as: tissue repair, control of local inflammation, or phagocytosis (Tab. 4, Fig. 4, Ref. 79).

Current occurence of intraspinal intradural and extradural communicating branches in the spinal canal

THE AIM of this work is to point out the intraspinal anatomical current occurrence interconnections between intradural and extradural nerve roots and their possible participation in radiculopathy.

METHODS

The anatomical study was performed in 43 cadavers with a mean age of 53.7. All intradural and extradural rami communicantes between nerve roots were excised and examined histologically for the presence or absence of nervous tissue.

RESULTS

Anatomical preparations revealed intradural and extradural rami communicantes in 9 cases (20.9 %), mostly in the cervical region in 5 cases and by plexus formation variations in 5 cases. Multiple extradural rami communicantes were observed in 6 cases (13.95 %), including the simultaneous occurrence of multiple intradural and extradural ones in 5 cases (11.6 %).

CONCLUSIONS

This study allowed us to identify and describe unpublished intraspinal current occurrence intradural-extradural rami communicantes of nerve roots and their interrelationships throughout the spinal canal with their potential influence on the clinical picture (Tab. 1, Fig. 4, Ref. 25).

Prevalent placement error of deep brain stimulation electrode in movement disorders (technical considerations)

BACKGROUND

Deep brain stimulation is an effective and safe technique. Displacement of the electrode relative to the optimal stimulation site can lead to insufficient effect and sometimes to the need of operative electrode re-position.

OBJECTIVE

This study was aimed to analyse targeting accuracy of deep brain stimulation electrode implantation to subthalamic nucleus (STN) and globus pallidus internus (Gpi). It detected possible causes of inaccuracy and prevalent shift to certain direction.

METHODS

Targeting accuracy was analysed in 47 patients with Parkinson´s disease (PD) and 11 patients with dystonia with bilateral implantation of deep brain stimulation electrodes between years 2009 and 2016.

RESULTS

A shift of electrode to prevalent direction was observed on the left side to medial and posterior and on the right side to lateral direction. Greater shift was observed on the left side and in a higher angulation of trajectory laterally. Movement of the electrode, because of its traction in anchoring device, was identified as a possible factor for prevalent electrode shift. Calibration of stereotactic coordinates to correct prevalent shift was used.

CONCLUSION

Targeting inaccuracy is the result of accumulation of errors in individual steps of electrode implantation. Direction of the shift can be random or it can be toward a prevalent direction. A correction of prevalent error can prevent a suboptimal electrode placement (Tab. 3, Fig. 11, Ref. 29).

Surgical treatment of nervus pudendus

An objective of our work was to clarify variations in pudendal nerve formation, as well as their possible impact on the clinical picture.Bilateral pudendal nerve course and formation was studied on 20 adult cadavers. Anterior approach was used in 15 of them, both posterior and anterior approaches were used in five of them. The prefixed type plexus formation was observed in eight cases (40 %). In these cases S1, S2 roots contributed to the formation of the pudendal nerve. In the postfixed type particularly the S3 root was dominant in two cases (66.7 %), and less the S4 root in one case (23.3 %) from three cases. Mostly the S2 root participated in its formation in 17 cases (85 %). The pudendal nerve branches run below the sacrospinous ligament on the level of the sacrospinous and sacrotuberous ligaments. The changes of the nerve and the branching therof were most evident from the anterior access below the sacrospinous ligament and in front of the sacrotuberous ligament. The inferior rectal nerve penetrating the sacrospinous ligament was seen in one case, it has risen from the pudendal nerve before entering the pudendal canal in four cases. The dorsal nerve of the penis has risen from the S1 root in two cases (10 %). We observed its branching before entering the pudendal canal in 15 cases (75 %). It has divided in the pudendal canal in other cases. This description may be useful particularly for the pudendal nerve block and the nerve saving surgeries directed on the relevant region (Fig. 8, Ref. 24).

Endovascular treatment of internal carotid and vertebral artery aneurysms using a novel pericardium covered stent

Intracranial aneurysm is a fairly common (often asymptomatic) condition. Subarachnoid hemorrhage associated with aneurysmal rupture is a potentially lethal event with a mortality rate as high as 50 percent and a high rate of disability among those who survive the initial hemorrhage, such that recently published guidelines support treatment of intracerebral aneurysms. The current treatment options include surgical clipping and endovascular treatment, but these are not without significant problems. Despite the trend toward endovascular treatment the rate of recurrence and complications is high. Current published evidence of the use of covered stent is limited to stents covered with polytetrafluoroethylene. It is now recognized that mammalian extracellular matrix represents an excellent scaffold material suitable for many therapeutic applications and glutaraldehyde treated pericardium has been widely used for many years due to its desirable features such as low immunogenicity and durability. This report describes the first published experience with the Aneugraft Pericardium Covered Stent (ITGI Medical, OR Akiva, Israel) in the treatment of internal carotid and vertebral artery aneurysms in three patients. In all three cases, the implantation of this novel device has resulted in successful closure of aneurysms.

MR imaging of late radiation therapy- and chemotherapy-induced injury: a pictorial essay

Radiation to the brain and adjuvant chemotherapy may produce late delayed changes from several months to years after treatment of intracranial malignancies with a reported prevalence of 5-24%. The pattern of treatment-related injury may vary from diffuse periventricular white matter lesions to focal or multifocal lesions. Differentiation of treatment-related injury from tumor progression/recurrence may be difficult with conventional MR imaging (MRI). With both disease processes, the characteristic but nonspecific imaging features are vasogenic edema, contrast enhancement, and mass effect. This pictorial essay presents MRI spectra of late therapy-induced injuries in the brain with a particular emphasis on radiation necrosis, the most common and severe form. Novel MRI techniques, such as diffusion-weighted imaging (DWI), proton MR spectroscopy (MRS), and perfusion MRI, improve the possibilities of better characterization of treatment-related changes. Advanced MRI techniques allow for the assessment of metabolism and physiology and may increase specificity for therapy-induced changes.

Post-therapeutical changes in the brain: novel trends in imaging and their infuence on external beam radiotherapy

Presented is the analysis of patients who underwent external beam radiotherapy (EBRT) to the brain in the period from 2003 to 2006 at the department of Radiation Oncology of the St. Elisabeth Cancer Institute. <p align="justify">The aim of our analysis was to identify risk factors of late delayed therapy induced injuries (LDTI) in the brain. The patients were regularly examined with magnetic resonance (MRI), including conventional and advanced techniques: perfusion imaging (pMRI), diffusion weighted imaging (DWI), MRI spectroscopy (MRS). The results from MRI were correlated with ¹⁸fluoro-deoxyglucose positron emission tomography (¹⁸FDG/PET) scans, as none of the listed method is sufficiently sensitive and specific by itself. Also clinical data records and treatment plans of these patients were analyzed. </p><p align="justify">In our cohort we found 6 patients with abnormal post-therapeutical changes, 4 of them with MR and ¹⁸FDG/PET scans characteristics for LDTI - radiation necrosis. In one patient biopsy was performed and radiation necrosis (RN) was confirmed. </p>

KEYWORDS

radiation necrosis, MRI, PET, 3D conformal radiotherapy (3D-CRT).

Neurofibroma of the vagus nerve in the cervical portion

OBJECTIVE

Neurofibromas of the vagus nerve on the neck are very rare. They are asymptomatic, slowly growing. We have seen only one case of neurofibroma of the vagus nerve in the mentioned location during last 22 years.

CLINICAL PRESENTATION

33-year-old patient with negative family history. She has observed increasing swelling on the right side of the neck for about 2 years. She complained of the disorders of swallowing, expectoration, aspiration episodes, strider, intermittent palpitations, breathlessness, frequent airway infections. Magnetic resonance (MR) and angiography (AG) showed expansion in the mentioned location.

CONCLUSION

We present our experiences with neurosurgical management of neurofibroma of the vagus nerve in the cervical portion using microscopic technique. We found only 9 described cases of surgical treatment of the neurofibroma of the vagus nerve in the neck location in available literature till 2007 (Fig. 6, Ref. 9).

Meningitis in diabetic patients

Community acquired bacterial (CBM) meningitis in diabetic patients was analyzed for risk factors and outcome in a cohort of 201 cases of meningitis within last 17 years: 15 patients with diabetes mellitus and meningitis were identified and compared for etiology and mortality as well as for neurologic sequellae with all CBM cases.

Comparison of postsurgical and community acquired bacterial meningitis--analysis of 372 cases within a nationwide survey

The aim of this study was to assess if differences in etiology and risk factors among 372 cases of bacterial meningitis acquired after surgery (PM) or in community (CBM) have impact on outcome of infected patients. Among 372 cases of bacterial meningitis within last 17 years from 10 major Slovak hospitals, 171 were PM and 201 CBM. Etiology, risk factors such as underlying disease, cancer, diabetes alcoholism, surgery, VLBW, ENT infections, trauma, sepsis were recorded and mortality, survival with sequellae, therapy failure were compared in both groups. Significant differences in etiology and risk factors between both groups were reported. Those after neurosurgery had more frequently Coagulase negative staphylococci (p<0.001), Enterobacteriaceae (p=0.01) and Acinetobacter baumannii (p=0.0008) isolated from CSF and vice versa Streptococcus pneumoniae (p<0.001), Neisseria meningitis (p<0.001) and Haemophillus influenza (p=0.0009) were more commonly isolated from CSF in CBM. Neurosurgery (p<0.001), sepsis (p=0.006), VLBW neonates (p=0.00002) and cancer (p=0.0007) were more common in PM and alcohol abuse (p<0.001) as well as otitis/sinusitis (p<0.001) and Roma ethnic group (p=0.001) in CAM. Initial treatment success was significantly more frequently observed among CAM (p<0.001) but cure after modification was more common in PM (p=0.002). Therefore outcome in both groups was similar (14.6% vs. 12.4%, p=NS).

Bacteremic meningitis is associated with inferior outcome in comparison to community acquired meningitis without bacteremia

Meningitis associated with bacteremia is rare. Bacteremic form of meningitis occurred in 28 of 201 cases of community acquired meningitis (14%) in Slovakia within last 17 years. Bacteremic meningitis was associated with diabetes (21.4% vs. 7.5%, p=0.02) and with higher treatment failures (32.1% vs. 9.5%, p=0.01) and higher mortality (25% vs. 12.4%, NS). In univariate analysis comparing 28 cases of bacteremic community acquired bacterial meningitis (BCBM) to all CBM, no significant risk factor concerning underlying disease (cancer, ENT infection, alcohol abuses, trauma, splenectomy, etc.) or etiology was observed apart of diabetes mellitus, which was more common among bacteremic meningitis (21.4% vs. 7.5%, p=0.02). Mortality (25% vs. 12.4%, NS) insignificantly but therapy failure (32.1% vs. 9.5%, p=0.01) was significantly more frequently observed among meningitis with bacteremia. N. meningitis was the commonest causative agent (8 of 28 cases) followed by Str. pneumoniae (6), gram-negative bacteria (6), S. aureus (4) and H. influenzae (2).

Bacterial meningitis after craniocerebral trauma in the community

Craniocerebral trauma is one of major risk factors for development of meningitis. We reviewed 30 cases of bacterial meningitis occurring in community after craniocerebral trauma. Alcohol abuse was significant risk factor occurring in trauma patients with meningitis present in 50% in our cohort (p=0.0001). The most common pathogen in posttraumatic meningitis was Str. pneumoniae (90% vs. 33.8%, p=0.0001). However mortality was very low, only 5% probably because of early diagnosis and treatment of patients at risk for bacterial meningitis but neurologic sequellea were significantly more common (p=0.00001) in patients after craniocerebral trauma.

Nosocomial meningitis caused by Staphylococcus other than S. aureus in children: multicentre study

Analysing 101 cases of nosocomial meningitis due to staphylococci other than S. aureus within last 15 years, coagulase negative staphylococci represented the commonest pathogen. Major risk factor for staphylococcal meningitis was prior neurosurgery, mainly ventriculoperitoneal shunt insertion. Ten of 101 cases were caused by glycopeptide intermediate resistant strains in patients pretreated with multiple combination of antibiotics including vancomycin and shunt exchanges: 76% of strains were also oxacillin resistant.

Reconstruction of the skull base after injuries

The aim of this study is presentation of 3 cases reconstructive surgery of the skull base after craniocerebral injury.

INJURIES AND METHODS

Extensive injuries of the skull base result in communication with paranasal cavities.

DIAGNOSTICS

The most serious part of the operation is the isolation of the liquor space from the external environment. Reconstruction surgeries of the skull base have significantly improved in recent years due to development of new methods in diagnostics and treatment. 3D CT reconstruction has proven to be particularly valuable for the verification of liquorea even in patients with inactive liquorea at the time of examination, as well as in patients with no CT defects or with normal MR finding.

TREATMENT

The use of firm and shapeable materials extends the possibilities of reconstruction surgery, the spectrum of surgical methods and approaches for extensive injuries of the skull base (Fig. 9, Ref. 3) Full Text (Free, PDF) www.bmj.sk.

Establishment, morphological, growth and cytoskeletal properties of 135-BCA carcinoma cell line derived from lung brain metastasis

Many cell lines have been established from lung cancer but carcinoma cell lines derived from brain metastases occur rarely. The carcinoma cells growth relatively slowly in comparison with brain cells which often overgrow the tumor cells in early passages. The origin of these rapidly dividing brain cells in carcinoma cultures is discussed with respect to the previous studies on adult human brain tissue cultures. It was found that the majority of cells in adult human brain cultures derived from brain biopsies of patients with non-cancer diseases do not express glial markers. Based on the previous studies we suggest that they are glial precursor cells. The high proliferative capacity and non-glial phenotype of these brain cells may lead to the suggestion that they are of cancer origin. In this study the establishment and characterization of a new carcinoma cell line 135-BCA is described. The tissue cultures were derived from brain metastasis of lung large cell carcinoma. The cell line is specific by the epithelial cell morphology and evident cytokeratins expression during the whole subcultivation. All tumor cells were strongly immunoreactive for vimentin and negative stained for glial fibrillary acidic protein (GFAP). The new cell line may prove of value in biological and therapeutic studies of lung cancer. In addition, the further comparative analysis may reveal the environmental influence of brain tissue on carcinoma cells.

Surgical treatment of injuries of nervus fibularis

STARTING POINT

In this retrospective study, we present the results of 40 surgeries of 40 patients that within the period of 15 years, i.e. from 1985 to 1999 were provided the treatment of 40 lesions of n. fibularis, historically treated as problematic in terms of successful healing. The work provides the fundamental lines of their surgery treatment.

MATERIAL AND METHODS

From the total number of 40, external neurolysis was performed to 20 patients. The remaining 20 patients were provided with reconstruction surgeries of the injured nerves, while 8 surgeries was done by suture of peripheral nerve and 12 surgeries were performed by nerve graft, in cases of complete and persisting neurological deficit and absence of action potential at EMG. The mechanism of lesion included the damages of nerve from elongation, with or without fracture, "sharp" or "blunt" lesions, lesions of shooting, compressions and iatrogenic injuries. If the spontaneous adjustment did not occur within the period of 2-6 months after the lesion, the patients underwent surgery. We performed the analysis of the efficiency of the surgical intervention depending on the following parameters: period of surgery from the lesion, patient's age, nature of lesion, degree of lesion, type of surgery intervention.

RESULTS

With 27 of 40 an effective adjustment was achieved preventing the sagging of the foot trace and with 25 of 40 protective sensitivity appeared. After neurolysis with 18 of 20 patients (90%) we achieved effective degree of adjustment in spite of heavy pre-surgical motor deficit. With 8 patients an "end to end" suture was performed and with 6 (75%) the degree of adjustment was 3 or higher. 12 patients requested reconstruction surgeries with the help of nerve grafts, the length of grafts varied from 4 to 20 cm. The grafts were shorter than 5 cm with 2 patients, 1 with cut lesion and 1 patient with iatrogenic lesion. With both patients the function was adjusted to the degree M4. With 1 of 4 patients (25%) with the graft of 6 to 12 cm and with none of 6 with the grafts from 13 to 20 cm the adjustment of the degree 3 or higher was not achieved. In this cases, however, we noticed partial adjustment of trophic and tonus, however at the absence of motor adjustment.

CONCLUSION

The pre-surgical and persurgical examinations are indispensable conditions for obtaining optimal results. It is worth of mentioning that surgical treatment proximal lesins of n. fibularis yielded better results than treatment of more distal lesions in the area of knee. (Tab. 5, Ref. 20.)

Radiation-induced meningioma with a long latency period: a case report

Multiple meningiomas were diagnosed in a 43-year-old man previously treated with high-dose craniospinal radiotherapy at the age of 7 years for medulloblastoma. We suggest that surveillance MRI after high-dose craniospinal radiotherapy should be extended to several (3-5) decades.

Results of peripheral nerve reconstruction by autograft

OBJECTIVES

This paper presents the results achieved in microtechnique surgeries performed during a 15-year-long period (1985-1999). By performing surgeries on 60 patients, 63 nerves were treated.

MATERIAL AND METHODS

In 42 patients with injuries of peripheral nerves of upper extremities, 45 nerves were reconstructed by autografts. 14 patients were subjected to reconstructive surgeries on peripheral nerves of lower extremities. In 4 patients we reconstructed the facial nerve by means of autograft. The analysis of surgical effects has been made in dependence on indicators as follows: period elapsed from injury to surgery, age of patient, nature of injury, length of autograft, location of injury, kind of nerve inflicted.

RESULTS

When assessing the results of reconstructive surgeries of peripheral nerves of lower and upper extremities we observed a big difference on the behalf of upper extremities. High efficiency can be seen in tibial nerve surgeries of lower extremities. In general we achieved good results in facial nerve reconstructions.

CONCLUSION

The crucial factor that has an impact on the result of surgery is that of the time which elapsed from injury to reconstructive surgery. The factor is especially marked in younger patients. (Tab. 7, Ref. 15.).

Co-expression of GFAP, vimentin and cytokeratins in GL-15 glioblastoma cell line

Glial fibrillary acidic protein (GFAP), vimentin (Vi) and cytokeratin (CK) intermediate filament (IF) proteins were studied in glioblastoma cell line GL-15. The immunofluorescence staining revealed strong positive staining for vimentin in all cultured cells. Approximately 20% of analyzed cells showed strong and 50% moderate intensity of staining for GFAP. About 3% of all cells were positively stained with a mixture of anti-CK monoclonal antibodies. The expression of all IF was not in relation to the cell density or days in vitro after passage. The double immunofluoresce revealed that all CK-positive cells express GFAP and vimentin. This study demonstrates the heterogeneity of the clonal GL-15 glioma cell line which consists in three immunocytochemically distinct cell types: Vi+/GFAP-/CK-, Vi+/GFAP+/CK-, and Vi+/GFAP+/CK+. These findings give further evidence about the expression of non-glial IF in cultured glioma cells.

[Microsurgical treatment of tumors and vascular lesions in the brain stem]

The authors present their experience with microsurgical replacement of brainstem lesions within the period 1989-1999. They operated on 35 patients with tumors and with KM? at age ranging from 2 to 65 years. The children suffered prevailingly from gliomas. KM was more frequent in adults. Ten adults were treated for tumors (4 gliomas, 3 haemangioblastomas, 2 primary lymphomas and 1 epidermoid). A correct surgical technique by use of microsurgical technology can replace relatively safely replace the tumor and vascular lesions even from the inside of the brainstem.

[Meningioma of the clivus]

Clivus meningeoma is a relatively rare tumor with difficult surgical accession. Large and giant tumors acquire a very close relation to the brain stem, cranial nerves and brain vessels. In 10 our of 13 patients, the large tumor diameter exceeded 4 cm, and in half of them it was larger than 5 cm (max. 6.5 cm). Small and medium-sized tumors were removed by means of simple neurosurgical approaches. All of the 10 large and giant tumors were removed by a combined supra-infratentorial presigmoid approach which enabled the approach to the whole tumor. Three recurrent tumors were removed subtotally, the primary surgical intervention removed 5 tumors radically, 4 subtotally and 1 partially. The entire removal was precluded due to infiltrative growth of the tumor localized in the cavernous sinus, firm adherence of tumor to the brain stem or to the vertebrobasillar vessels. Authors' own experience support the data from literature dealing with the relationship of unfavourable results to the size of tumor. Permanent impairment of cranial nerves (38.5%) occurred mostly in large and giant tumors. One death (7.7%) during the peri-operative period (up to one month following operation), as well as the second that occurred in later period succeeded the removal of a giant tumor. Regarding the character of the relationship of large clivus meningeoma to the surrounding nerve and vascular structures, the future improvement of functional results can be expected especially owing to early diagnosis. (Tab. 2, Fig. 2, Ref. 19.)

Heterogeneity of keratin intermediate filaments expression in human glioma cell lines

Keratin intermediate filaments (Ifs) are specific for epithelial cell differentiation. This study demonstrates the presence of keratin in two recently established human glioblastoma cell lines 8-MG-BA and 42-MG-BA. Immunofluorescence staining was performed on cells within passage 230 to 235 using monoclonal pan-cytokeratin antibodies. The cells were analyzed during several DIV at different cell density. Keratin-positive stained cells reached 5 to 7% in 8-MG-BA and less than 0.1% in 42-MG-BA cell line. The presence of keratin-positive cells was independent on cell density and days in vitro. Keratin-positive cells appeared unevenly distributed in both cell lines. They were observed as single or areas of keratin-positive cells. The morphological features of keratin-positive and keratin-negative cells were similar. The results are discussed with respect to previous studies on glial fibrillary acidic protein (GFAP) and vimentin to show the heterogeneity of IFs expression in glioma cell lines.

Petrous apex cholesteatoma

Primary or secondary petrous apex cholesteatoma requires surgical management. We describe here live patients with cholesteatoma in the petrous apex on whom different surgical approaches to this region were used. Translabyrinthine transcochlear (transotic) approach with VII-XII anastomosis was used in four patients. In one patient middle fossa approach with otic capsule and facial canal leaving intact was used. All patients are without recurrence of cholesteatoma with improving of the facial nerve function in one case. We discuss specific pathologies of the petrous apex, the surgical approach to this region indicated according to the size and type of pathology diagnosed, hearing loss and facial nerve function. Possible complications of this surgical procedure and their management are also discussed.

[Concurrent cavernous and venous cerebral angiomas]

Presence of venous angioma (VA) in a close vicinity of cavernous angioma (CA) of the brain enhances the risk of bleeding from CA. However, VA drains the venous blood from surrounding brain tissue and should be left in place during surgical removal of CA. Coincidence of CA and VA was found in 6 of 44 patients operated on for 45 CA during a six years period (1993-1998). Coincidental VA were found more often with the CA located in the deep structures of the brain, in the thalamus and the brainstem (5 of 15 cases) than with the superficial CA (1 of 30 cases). The most valuable diagnostic method was T1 weighted MR imaging with contrast enhancement, less reliable was nonenhanced T1 or proton density weighted imaging. Finding of the VA may positively influence the decision making concerning the indication for surgery and the selection of the most appropriate surgical tactics. (Tab. 1, Fig. 2, Ref. 15.)

Characterization of two new permanent glioma cell lines 8-MG-BA and 42-MG-BA

The establishment and characterization of two permanent glioma cell lines (8-MG-BA and 42-MG-BA) are described. Both cell lines were derived from the human glioblastoma multiforme. Analyzed cells were within the passage 200 to 220. The cells in both cultures showed similar morphology. In majority they consisted from flat polygonal cells. Growth kinetic studies demonstrated a population doubling time of 20 to 24 h in cell line 8-MG-BA and 48 to 54 h in cell line 42-MG-BA. The cell lines showed different hyperdiploid karyotypes. The immunofluorescence staining was performed for glial fibrillary acidic protein (GFAP) and vimentin. In the culture 8-MG-BA only a small amount of cells showed the GFAP-positive staining. At confluent 42-MG-BA culture the GFAP-positive cells reached 50 to 70% of all cells. Vimentin was found in all glioma cells in both cultures.

1H NMR ganglioside ceramide resonance region on the differential diagnosis of low and high malignancy of brain gliomas

1. The high-resolution 1H NMR (MRS) spectra of human brain tumor homogenates revealed a broad resonance at 5.3-5.4 ppm in glioblastoma multiforme (N = 16) and brain metastases (N = 3). The broad resonance was identified as ceramide, a sphingosine-fatty acid combination portion of ganglioside, indicating an elevated abundance of monounsaturated fatty acids. GLC analysis of gangliosides in the highly malignant glioblastoma multiforme revealed that the elevated monounsaturated fatty acid is oleic acid (C18:1). The resonance at 5.3-5.4 ppm region was not detectable in normal human brain (N = 2), in meningiomas (N = 2), or in low-grade astrocytomas (N = 12). In normal human brain the abundance of monounsaturated fatty acid is minimal. 2. This investigation was made possible because the method of producing homogenate resulted in (i) no loss of lipids during the process and (ii) a well-homogenised sample, with (iii) no loss in chemical integrity. 3. The properties of tumor gangliosides include antigenic specificity and immunosuppressive activity and the ceramide, a sphingosine-fatty acid combination, noticeably influences the ganglioside immunosuppressive activity. 4. The observation of 1H NMR ceramide resonance in high-malignant brain tumors emphasizes the dramatic role of aberant gangliosides and ceramide precursors on the grade of malignancy and invasiveness. 5. Further insight into the specific nature of the ceramide portion of gangliosides in grading the malignancy of brain tumors should be investigated further.

Pineal region teratomas in children

Immature or mixed mature/immature teratomas of the pineal region were removed radically in three children. After a period of 26 and 25 months, two patients with immature teratomas are alive and well, whereas in the third patient a mixed teratoma locally recurred and caused a fatal rise of intracranial pressure 11 months after the operation. Regular examinations of tumor markers and neuroradiological investigations are mandatory after radical surgery and adjuvant radio- and chemotherapy.

[Octreotide in the treatment of thyrotropin-secreting pituitary adenomas]

The authors detected in a 30-year-old patient a very rare type of hyperthyroidism caused by a thyrotropin secreting pituitary adenoma. Scintigraphic examination of the pituitary by means of 111In radiolabelled octreotide revealed an increased accumulation of the radiopharmaceutical preparation in the tumour, which confirmed the high density of somatostatin receptors. After onset of octreotide treatment (Sandostatin, Sandoz, Switzerland) 3 x 100 ug/day by the s.c. route a brisk decline and normalization of thyrotropin already after the first dose was recorded. The thyroxine concentration declined slowly to the upper range of normal values. After 5 months treatment despite the positive response to receptor scintigraphy diminution of the adenoma was not recorded. Again an increase of thyrotropin above the upper limit of the reference range and a marked rise of thyroxinaemia were observed. Six months after radical selective trans-sphenoidal adenomectomy normal pituitary function was confirmed.

[Does selectivity in radical adenomectomy in invasive hypophyseal adenomas increase the risk of recurrence?]

Between 1989 and 1992 we operated 52 patients primarily due to pituitary adenoma. The tumor growths were evaluated microsurgically or histologically as invasive in 29 of them. Radical adenomectomy was achieved in 65.5% of patients with invasive and in 91.3% of patients with noninvasive pituitary adenoma--in 40 cases altogether. Although it was possible to identify and preserve pituitary tissue remnants in 23 cases, the real selectivity, confirmed by biochemical testing, was finally achieved only in 16 of them. Only one recurrence, 8 months after the radical nonselective removal of nonfunctional extrasellar invasive adenoma occurred during the median follow-up time of 2.61 years (minimal follow-up time 1 year). We have found out no significant differences in the recurrence rates between invasive and noninvasive pituitary adenomas after their radical selective and nonselective removal. We suppose that nonselective radical adenomectomy is not necessary to prevent the recurrence of the invasive pituitary adenoma. (Tab. 7, Ref. 15.)

[Radical and selective removal of hyperfunctional hypophyseal adenomas using a transsphenoidal approach]

The authors investigated the possibility of radical removal of adenomas of the pituitary (AH), while preserving remnants of pituitary tissue, in 23 patients with primarily operated hyperfunctional AH producing PRL (14 patients), STH (8 patients) and ACTH (1 patient). Normalization of the pathologically elevated hormone level was achieved by the transsphenoid operation without supplementary treatment in 13 of 16 patients with defined and in 3 of 7 patients with invasively growing AH (PRL in 10, STH in 5 and ACTH in one patient), i.e. in 69.5% Identification and preservation of remnants of the pituitary was possible in 20 patients (in all 16 with defined and in 4 of 7 with invasive AH); 17 of them (73.9%) do not need hormonal substitution. Radical and at the same time selective adenomectomy was achieved in 14 patients (60.9%) incl. three patients with invasively growing tumours. The improved activity of the pituitary is manifested clinically after successful operation in particular in young patients by improved gonadal function.

[Epidural hematomas in the posterior cranial fossa]

In the course of twenty years 92 patients with intracranial epidural haematomas (EH) were operated. In five these patients, i.e. 5.4%, the EH was in the posterior cranial fossa (EHPF). Focal symptoms of compression of the cerebellum and the lower cranial nerves developed only in subacute EHPF. In acute EHPF it was masked by manifestations of an affection of the brain stem. Direct evidence of EHPF was produced by AG. The best diagnostic method is computed tomography. Attention to EHPF can be however, drawn also clinical sings of injury of the bask of the skull or the finding of a fracture of the occipital bone on an X-ray picture of the skull. Evacuation of the EHPF provides favourable perspectives of a normal future life even on patients who are in a poor condition incl. signs of and impaired respiration.

[Compression of structures in the visual pathway by arteries of the circle of Willis in suprasellar tumors]

The mechanical compression of optic nerves, of the chiasma of optic pathways by vessels of Willis circle was revealed in 12 of 34 necropsies of extensive craniopharyngiomas and pituitary adenomas and in three of 109 patients operated on account of these tumours. The localization of pressure changes, from shallow grooves on the surface of optic structures to almost complete interruption of their anatomical continuity, depended on the localization of the tumour in relation to the chiasma. This relation was influenced in particular by two factors, the site of the primary development of the tumour and the premorbid localization of the chiasma. Impaired optic functions were the result of the action of pressure of the tumour exerted on the area and pressure of firm vascular structures on a defined portion of the optic pathway, which begins to act only when the tumour is large and has a more malignant effect than the pressure of the tumour itself.