Endoscopic treatment of in utero diagnosed multiloculated interhemispheric cyst in a newborn: case report

Interhemispheric cysts, often associated with agenesis of corpus callosum, are rare lesions. The optimal treatment is still controversial. Placement of cystoperitoneal shunt and open microsurgery are traditional treatments. Neuroendoscopy in children is due to its minimal invasiveness a new emerging option. There have been a few published cases on neuroendoscopic treatment of interhemispheric cyst in children. The authors document the youngest reported child with multiloculated interhemispheric cyst that was treated with neuroendoscopy. The cyst was detected in a male fetus in 35th week of gestation and in utero magnetic resonance imaging was performed in 37th week of gestation. After delivery, progressive macrocrania with signs of raised intracranial pressure developed. Endoscopic cystoventriculocisternostomy was performed 28 days after the birth. There was a marked symptom relief. One month after the surgery, magnetic resonance showed shrinkage of the cyst and expansion of the brain parenchyma. After a 2-month follow up period, the child showed normal neurologic development and head circumference increased by only 0.5 cm. The created fenestrations enabled the brain to expand. Neuroendoscopic treatment,of interhemispheric cysts should be considered the operative technique of choice in newborns. Although the intracranial pressure and the size of the cyst have decreased, long-term follow up is necessary and future studies on more cases are needed.

Multiple indicators model of long-term mortality in traumatic brain injury

OBJECTIVE

To examine the prognostic ability of protein S100B, neuron-specific enolase (NSE) and glial fibrillary acid protein (GFAP) for prediction of 1-year mortality in patients with traumatic brain injury (TBI) in relation to clinical and radiological characteristics of TBI.

METHODS

Brain injury was quantified in 84 patients (Glasgow Coma Scale [GCS] ≤ 12) using clinical (GCS, pupils), radiological (computed tomography [CT] classification and individual CT characteristics) and biochemical (S100B, NSE and GFAP) data at admission and in the acute post-injury period.

RESULTS

Initial and peak S100B, NSE and GFAP concentrations were higher in non-survivors (n = 26) than in survivors (p-value range: <0.001-0.018). Cox regression showed that GFAP and S100B concentration and the temporal profile of S100B were more powerful independent predictors of mortality than baseline clinical and radiological characteristics or clinical and radiological indicators of neurological deterioration. The prognostic models containing admission variables and those available during the subsequent clinical course showed the same discrimination ability (area under receiver characteristic curve 0.92), but the model based on variables available in the acute post-injury period calibrated better (p = 0.428).

CONCLUSION

Mortality at 1-year post-TBI is accurately predicted by the combination of GFAP and S100B concentration and clinical and radiological characteristics at admission or in the acute post-injury period.

Clinical features and therapeutic outcomes of patients with acromegaly: single-center experience

The aim of this study was to review the outcome of acromegaly treatment, as well as co-morbidity and mortality in a series of patients with acromegaly attending a single center in the last 10 yr. In that period, 53 patients were treated for acromegaly. Transsphenoidal operation was applied as the first-line therapy in 94.3% of patients and it led to disease remission in 59.2% of them. The remission criteria included a nadir GH<1 μg/l after glucose load, and normal age-related IGF-I levels. The remission rate after transsphenoidal surgery was significantly higher in the group of patients with microadenoma (76.9%), than in the group of patients with macroadenoma (52.8%). Patients with invasive tumors had remission rate of 16.7% after transsphenoidal surgery. There were no perioperative deaths. As the second-line treatment somatostatin analogues, radiotherapy, and dopaminergic agonists were used. Hypertension and diabetes were the most frequent co-morbidities in the group of patients. After successful treatment, 30% of patients with diabetes or impaired glucose tolerance had significant improvement of glycemic control. Transsphenoidal surgery is the appropriate firstline therapy in patients with somatotropinoma. Medical and radio-therapy should be reserved as the second-line therapy after surgery failure.

Decreased peak bone mass is associated with a 3-bp deletion/insertion of the CYP19 intron 4 polymorphism: preliminary data from the GOOS study

Finding that estrogen plays an important role in bone homeostasis in men prompted research on relationship of polymorphism at the CYP19 gene and the bone mass. Therefore, influence of 3-bp deletion/insertion polymorphism of CYP19 (TTTA)7 allele on the peak bone mass attainment in males was studied. Fifty-eight unrelated male participants, aged 21-35, were selected depending on the presence of (TTTA)7 (no.=19) or (TTTA)7-3 (no.=39) alleles from the initial cohort of 92 young males. Heterozygotes (TTTA)7/(TTTA)7-3 (no.=13) were not included in the analysis. Serum levels of estradiol, free testosterone, 25-hydroxyvitamin D, bone alkaline phosphatase, osteocalcin, and beta-crosslaps were measured. Bone mass was measured by DXA at the hip and at the spine. (TTTA)7-3 allele was associated with significantly lower femoral neck bone mineral density (BMD) (p=0.02). Logistic regression model indicated strong association of (TTTA)7-3 allele with low BMD in the range of osteopenia/osteoporosis (p=0.014, odds ratio 12.36, confidence intervals 1.65-92.46). In the present study association of 3-bp deletion polymorphism of the (TTTA)7 allele with decreased peak bone mass in males is reported for the first time. However, further studies are necessary to elucidate the functional relevance of this polymorphism.

Discriminatory ability of calcaneal quantitative ultrasound in the assessment of bone status in patients with inflammatory bowel disease

A high incidence of bone disease in patients with inflammatory bowel disease (IBD) requires frequent monitoring of skeletal status and, for that reason, evaluation of radiation-free technology is an issue of interest. Our objective was to appraise the parameters of calcaneal quantitative ultrasound (QUS): broadband ultrasound attenuation (BUA), speed of sound (SOS) and stiffness index (QUI), and establish their t-score values to investigate discriminatory ability of QUS in IBD patients with metabolic bone disease. The study included 126 patients (Crohn's disease [n = 94] and ulcerative colitis [n = 32]), and 228 age- and sex-matched healthy volunteers. Bone status was evaluated on the same day by calcaneal QUS and dual-energy x-ray absorptiometry (DXA) at spine (L1-L4) and total hip. All QUS measurements were lower in patients compared with healthy controls (BUA p < 0.001; SOS p < 0.001; QUI p < 0.001) and correlated significantly but inversely with disease duration (r = -0.3, p = 0.002). There was no difference with respect to type of disease (Crohn's disease or ulcerative colitis) or corticosteroid therapy. All three QUS t-scores were significantly lower in patients who had previously sustained fragile fractures (n = 28) than in those without fracture in their history (n = 98) (t-scores: BUA -2.0 vs. -1.3, p = 0.008; SOS -2.1 vs. -1.4, p = 0.02: QUI -2.3 vs. -1.5, p = 0.009). Axial DXA was not significantly different between the fracture and nonfracture patients (-1.7 vs. -1.2, p = 0.1), whereas total hip DXA showed a discriminatory power between the two (-1.6 vs. -0.7, p = 0.001). Patients with t-score < -1.0 scanned by DXA were classified as bone disease. The sensitivity of QUS to identify bone disease was 93% and specificity 63%. The sensitivity of QUS to detect osteopenia was 84% and 72% for osteoporosis. Alternatively, lower negative QUS t-score cutoff <or= -1.8 identified 83% of osteoporosis at lumbar spine and 100% at total hip. All three QUS variables had t-scores less than -1.8 when osteoporosis was detected at both spine and hip. However, the subgroup of IBD patients with QUI t-score cutoff <or= -1.8 still included 26% of individuals with normal bone status. Calcaneal QUS measurements may identify patients with IBD who are at a higher risk of fracture independently of DXA measurements. However, QUS showed poor agreement with bone status scanned by DXA and a low discriminatory power between osteopenia and osteoporosis.

Pacinioma of the cauda equina

Lesions composed of Pacinian corpuscles or showing Pacinian corpuscle differentiation have usually been described in relation to benign tumours of the peripheral nervous system or reactive hyperplastic processes. On the other hand, mature Pacinian corpuscles have occasionally been detected as part of intraspinal lumbosacral lipomas, a rare developmental anomaly usually associated with spina bifida. A lesion of the cauda equina composed of numerous mature Pacinian corpuscles and nerve fascicles embedded in adipose tissue in association with spina bifida occulta is described in a 5-month-old male with a sacral red papula. Magnetic resonance imaging (MRI) revealed a cord-like mass in the region of the cauda equina, presumably connected to the subcutis. With the exception of a low lying, tethered spinal cord, there was no neurological deficit and the range of motor development was normal. In March 2005, at 17 months, surgery was carried out. A cord of yellow tissue was found running from the subcutis through the bone defect into the lumbosacral spinal canal. Intradurally, it ran parallel to the cauda equina, terminating at the conus medullaris. Fifteen months after the surgery the development of the child was normal. Only two similar cases have been reported so far. Due to their occurrence in the sacrococcygeal region and association with developmental anomalies, they have been regarded as malformations and the term Pacinioma has been suggested. Our case with clusters of Pacinian corpuscles may represent a rare variant of complex intraspinal lumbosacral lipomas, closely related to Paciniomas reported by Bale.

Somatosensory evoked potentials in children with brain ventricular dilatation

AIM

To determine possible nerve conduction changes in the somatosensory pathway in children with brain ventricular dilatation and to estimate the relation between the ventricular size and somatosensory evoked potentials (SEP).

METHODS

Twelve children with ventricular dilatation (frontal and occipital horn ratios >0.44) and 19 children without ventricular dilatation (control group), aged between 2 and 15 years, were included in the study. Somatosensory evoked responses to median nerve stimulation were recorded in both groups. Evoked potentials were recorded by silver/silver chloride cup electrodes from Erb's point in the supraclavicular fossa (wave N9), the cervical spine at the C7 vertebral prominence (wave N13), and the scalp above the contralateral sensory cortex at the point C3' or C4', 1 cm behind the C3 or C4 site in the standard 10-20 system (wave N19). Computed tomography scanning was performed to estimate ventricular dilatation.

RESULTS

The conduction time of the central somatosensory pathway (N19-N13 interwave latency) was significantly longer in the children with ventricular dilatation than in the control group (P = 0.046). A statistically significant but weak correlation was found between the frontal and occipital horn ratio values and the N19-N13 interwave latencies in the subjects with enlarged ventricles (r = 0.579, P = 0.045).

CONCLUSION

Ventricular dilatation is associated with prolonged conduction of the central part of the somatosensory pathway in children. Early detection and treatment of hydrocephalus could be useful in preventing long-term consequences of high intraventricular pressure.

Intracranial pressure and biochemical indicators of brain damage: follow-up study

AIM

To investigate the relation between metabolic parameters of the brain tissue, as direct indicators of real metabolic conditions within the brain, and intracranial pressure, as the consequence of pathophysiological changes.

METHODS

Twelve patients with closed head injuries were followed up for 24 hours after injury. A Codman parenchymal intracranial pressure and a Neurotrend electrode were inserted within 3 hours after injury to monitor parenchymal intracranial pressure, brain tissue partial oxygen pressure (P(br)O2), brain tissue partial carbon dioxide pressure (P(br)CO2), pH, and brain tissue temperature. Data detected at 8-hourly intervals were compared with repeated measures analysis of variance.

RESULT

At the initial observation, the mean value of intracranial pressure was 22.2 +/- 3.2 mm Hg. Although it increased at the second and decreased at the third measurement, the differences between the measurements were not significant (P = 0.320). The value of P(br)CO2 was increased from the beginning (63.3 +/- 6.0 mm Hg), whereas P(br)O2 was within the normal range at the first measurement (38.9 +/- 6.9 mm Hg), but significantly decreased after 8 hours (P = 0.004), remaining low at later time points.

CONCLUSION

After brain injury, changes in P(br)CO2 are visible earlier than those in P(br)O2. Improvement in intracranial pressure values did not necessary mean improvement in the brain tissue oxygenation. In addition to intracranial pressure, P(br)O2, P(br)CO2 and pH should also be monitored, as they directly reflect the real metabolic conditions within brain tissue and may be used in predictions about the outcome and possible therapeutic approaches.

A systematic review of brain injury epidemiology in Europe

BACKGROUND

The world's literature on traumatic brain injury (TBI) grows annually including new reports on epidemiologic findings from many regions. With the wide variety of reports emphasizing various factors it is useful to compile these findings, hence the objective of this report. Thus, we describe epidemiological factors from European studies largely published in the last 20 years.

METHOD

The Medline was searched for TBI related articles from about 1980 to 2003 including terms such as "epidemiology", "head injury", "brain injury" and others. From the research reports identified, we checked references for additional relevant reports and from those reports we abstracted data on TBI incidence, severity, external cause, gender, mortality, prevalence, cost and related factors.

RESULTS

Twenty three European reports met inclusion criteria and included findings from national studies from Denmark, Sweden, Finland, Portugal, Germany, and from regions within Norway, Sweden, Italy, Switzerland, Spain, Denmark, Ireland, the U.K. and France. An aggregate hospitalized plus fatal TBI incidence rate of about 235 per 100,000 was derived. Prevalence rate data were not reported from any European country. An average mortality rate of about 15 per 100,000 and case fatality rate of about 11 per 100 were derived. The TBI severity ratio of hospitalized patients was about 22:1.5:1 for mild vs. moderate vs. severe cases, respectively. The percentages of TBI from external causes varied considerably and several reports reported an association of alcohol use with TBI. Outcome or disability findings were mixed and inconsistent.

INTERPRETATION

It was difficult to reach a consensus on all epidemiological findings across the 23 published European studies because of critical differences in methods employed across the reports. We highly recommend the development of research guidelines to standardize definitional, case finding, and data reporting parameters to help establish a more precise description and hence utility of the epidemiology of TBI in Europe.

Calcaneus ultrasound in males: normative data in the Croatian population (ECUM study)

Limited number of dual X-ray absorptiometry (DXA) devices in Croatia makes this diagnostic technique unavailable to the majority of the population. Quantitative ultrasound (QUS) of the calcaneus could be an alternative tool for assessing fracture risk. However, age-specific normative data should be obtained before using the QUS in everyday clinical practice. The aim of our Epidemiology of Calcaneus Ultrasound in Males (ECUM) study is to establish the normative QUS data in a healthy sample of Croatian males. A total of 1002 male participants, aged 20-99, recruited in different Croatian counties, were included in the study. In each subject broadband ultrasound attenuation (BUA), speed of sound (SOS) and quantitative ultrasound index (QUI) of the left calcaneus were measured using the Sahara ultrasound device (Hologic). The coefficients of variation were 2.85 for BUA, 0.37 for SOS and 2.49 for QUI. Significant declining with age was found for all three parameters, BUA (p<0.001), SOS (p<0.001) and QUI (p<0.001), with respective r values 0.14, 0.27 and 0.23. The peak SOS (1,562.8+/-28.5 m/sec) and QUI (103.6+/-16.5) values were observed in the third decade, whereas the peak BUA value (86.2+/-19.2 db/MHz) was observed in the fourth decade. A subgroup of 103 participants, aged 20-29, was used to estimate young adult mean and SD for QUI and calculate the T-scores. Using the World Health Organization diagnostic criteria the rates of osteoporosis (T-score<-2.5) in the males aged 50 and older was 5.8%. However, when we used the cut-off value of the T-score<-1.8, as previously suggested, prevalence of osteoporosis in Croatian males >50 yr was 16.2%. Although further studies might improve our understanding of the QUS role in the fracture prediction, we hope that the results presented here will improve the clinical management of osteoporosis in males.

Middle cranial fossa schwannoma of the facial nerve

A case of an intratemporal lobe and middle cranial fossa neurinoma of the facial nerve is presented. Complete excision of the tumour was carried out.

Molecular genetics of malignant insulinoma

Malignant insulinoma is an rare form of cancer with poor prognosis and a reported 5-year survival of 35%. Relatively little is known about the etiology of this disease or of the oncogenes and tumor suppressor genes that participate in its genesis and progression. To address this issue, several protooncogenes, including K-ras, N-ras, erbB-2, erbB-3,c-myc, c-fos, c-jun were examined. Also analyzed was the expression of the growth factors TGF-alpha, EGF, and insulin as well as the EGF receptor (EGF-R), p53 and the putative anti-metastasis gene nm23-H1. These were examined in malignant insulinomas, benign insulinomas, pancreatic B cell hyperplasias and in normal endocrine pancreas. Normal endocrine pancreas showed moderate immunoreaction for c-myc and a strong reaction for insulin. All other parameters were negative. Benign pancreatic B cell hyperplasias were slightly or moderately positive for N-ras and TGF-alpha, and were weakly positive for EGF-R. They were strongly positive for c-myc and insulin. In malignant insulinomas there was strong immunoreaction for c-myc, TGF-alpha, N-ras, K-ras and p53. Insulin reaction was moderate or strong. Molecular genetic studies have been performed for the presence of activating point mutations in codon 12 of the c-K-ras oncogene. Mutations were detected using primer-mediated, mutant-enriched, polymerase chain reaction-restriction fragment length polymorphism analysis and were further characterized by allele-specific oligonucleotide hybridization. Four out of six patients with malignant insulinoma and two out of eight patients with benign insulinoma harbored K-ras point mutations at codon 12. All patients with mutated K-ras oncogene also had elevated levels of p53 protein as well as c-myc and TGF-alpha. In one extremely malignant case we found concomitant mutation at codon 12 of K-ras and codon 61 of the N-ras gene. Our data are consistent with the idea that malignant progression is accompanied by the progressive accumulation of multiple genetic lesions and suggest that activation of myc, TGF-alpha and ras genes may be early events in the development of insulinoma.

Blood clot evacuation in aneurysm surgery in the acute stage (arguments pro and con)

In a series of 122 consecutive patients operated on by the senior author for rupture of an aneurysm the pterional approach was used in all but a few cases. A microsurgical technique was invariably utilized from opening to closing of the dura. Nearly half of our patients underwent surgery within the first week after subarachnoid haemorrhage (SAH). In the majority of cases operated on in the acute stage, a sizable subarachnoid blood clot was evacuated, mostly from the basal cisterns. The authors present their own experience in the field to show the superiority of the technically more demanding surgery carried out within the first days following SAH over other therapeutic procedures.