Tubargravidität nach Hysterektomie

A 41 year old woman had been submitted to a supravaginal uterine amputation in 1978 and to extirpation of the cervical stump in 1981. In 1982 she then developed a tubal pregnancy. - There have been only 30 reports regarding ectopic gestation diagnosed after previous complete hysterectomy in world literature since 1895. In 20 cases conception occurred some time before hysterectomy, in the remaining 10 cases, however, thereafter ("early" or respectively "late" type of extrauterine gestation, with regard to the date of hysterectomy). Probably ectopic pregnancy following complete hysterectomy could be diagnosed more often in the future, provided that the possibility of its manifestation is carefully taken into consideration.

Results and outcome of neurosurgical treatment for extradural metastases in the cervical spine

Metastatic lesions are the most common spinal extradural tumours. Significant advances in their neurosurgical management have been made in the last two decades. This retrospective study was undertaken to summarise the long-term results of surgery and the outcome of patients with cervical spine metastases. Sixty-two patients with cervical spine metastases who underwent instrumented spinal surgery at a single centre in an 12-year period (1989-2000) were analysed. All patients presented with local pain and with either neurological deficits, spinal instability, or a combination of both. A standard anterior approach to the cervical spine was chosen, and a partial or total vertebrectomy and vertebral body replacement with subsequent anterior instrumented fusion were carried out in all cases. General and neurological status was evaluated at baseline and in regular intervals thereafter. Plain X-rays, CT, and MRI were used for preoperative planning. Postoperative follow-up was done by X-rays. The mean follow-up time for all patients was 1.5 years. A stable bony fusion of the cervical spine was achieved in 60 patients (96.8%), with two additional patients needing a further procedure for maintaining the mechanical stability of the spine. There was mild early surgery-related morbidity, and no mortality. The most frequent temporary surgery-related side effect was reversible vocal cord paresis in 5 cases (8.0%). There were 3 cases (4.8%) of early instrumentation failure. One of these was symptomatic and underwent second-look surgery. No late complications occurred due to instrumentation hardware failure. The 1-year survival rate of all patients after surgery was 58%, and the 2-year survival rate was 21%. Our results demonstrate that surgical removal of extradural metastases with subsequent instrumented fusion is a low-morbidity and low-complications procedure with high rates of permanent stabilisation of the compromised cervical spine. In addition, it improves the neurological deficits and relieves the local pain in a significant proportion of patients. Excellent local control of malignant disease can be achieved by the surgical procedure aided by subsequent local and systemic adjuvant therapy. Overall survival time and prognosis of the patients, however, are mainly depending on the type and the stage of the primary malignancy.

Long-term intrathecal infusion of drug combinations for chronic back and leg pain

Continuous intrathecal infusion of analgesic drugs by implantable pumps is recognized as an established treatment option for patients with chronic pain resistant to oral or parenteral medication. Polyanalgesia, the simultaneous use of more than one intrathecal analgesic drug, is practiced relatively often, but there are only a few published clinical studies on intrathecal polyanalgesia for chronic nonmalignant pain. This pilot study represents a long-term evaluation of a treatment regimen consisting of intrathecal morphine admixed with bupivacaine, clonidine, or midazolam in patients with chronic nonmalignant back and leg pain due to degenerative lumbar spinal disease. Twenty-six adult patients have been treated by intrathecal programmable pump-controlled infusion of analgesic drugs and followed for up to 3.5 years (27 +/- 11 months). Combination of morphine with a second drug was used in 10 cases, morphine with 2 additional drugs in 12 cases, and morphine with 3 additional drugs in 4 cases. Mean daily doses at 24 months after pump implantation were 6.2 +/- 2.8 mg for morphine, 2.5 +/- 1.5 mg for bupivacaine, 0.06 +/- 0.03 mg for clonidine, and 0.8 +/- 0.4 mg for midazolam. Nineteen patients reported excellent or good long-term treatment results, 6 patients had sufficient results, and only 1 patient complained of poor therapeutic efficacy. No long-term clinical side effects of intrathecal polyanalgesia were noted. Mean morphine dose had to be increased from 1.2 mg at baseline to 5.1 mg at 24 months due to tolerance development and disease progression. This experience suggests that intrathecal polyanalgesia employing morphine combined with additional nonopioid drugs can have a favorable analgesic efficacy in patients with complex chronic pain of spinal origin, and lacks major drug-related complications.

Secondary tumor formation after stereotactic biopsy for intracerebral metastatic disease

BACKGROUND

There are only a few published cases of iatrogenic tumor seeding and distant neoplastic growth along the path of the cannula after stereotactic biopsy.

CASE DESCRIPTION

We report the case of a female patient with a solitary lung cancer metastasis in the left parietal brain lobe. The tumor was stereotactically biopsied and treated by radiosurgery. One month after the initial biopsy, a smaller de novo tumor mass located along the track of the stereotactic cannula was detected by contrast-enhanced MRI. The spatial location of this neoplastic nodule and the short time before development of a macroscopic lesion seemed to confirm iatrogenic tumor cell spread due to the stereotactic procedure.

CONCLUSION

Our findings and the reviewed literature suggest that this complication is rare. Nevertheless, neurosurgeons should be aware of the potential risk and, if necessary, should be able to modify the technical procedure and the adjuvant treatment.

Immune response induced by retrovirus-mediated HSV-tk/GCV pharmacogene therapy in patients with glioblastoma multiforme

This study was conducted to investigate immunological components of somatic gene therapy for primary glioblastoma multiforme (GBM) in adults. It involved 13 patients treated by surgical resection of tumor with subsequent radiation therapy. Seven of them received additional herpes simplex virus thymidine kinase/ganciclovir (HSV-tk/GCV) gene therapy by direct intracerebral injection of retrovirus (RV) vector producing cells (VPC) during tumor surgery and subsequent systemic administration of GCV. Peripheral blood for FACS immunophenotyping, isolation of peripheral mononuclear cells (PMNC), and serum ELISA assays for IL-12 and soluble Fas ligand (sFasL) was collected daily during the first 4 post-operative weeks. Tumor specimens were obtained at primary or recurrent surgery and at autopsy. Tumors from gene therapy patients showed varying degrees of peritumoral necrosis around the former tumor resection cavity. Numbers of tumor-infiltrating lymphocytes found weeks after gene therapy were not significantly increased compared with primary tumors. Mitotic tumor cells were sparse close to the VPC injection sites, but abundant in brain areas somewhat distant from these sites. Serum ELISA revealed significantly increased sFasL and IL-12 levels in the gene therapy group compared with controls. Immunophenotyping of PMNC did not show a significant activation of T cells or NK cells during gene therapy. Interferon gamma secretion was evaluated by ELISPOT assays employing PMNC cocultivated with autologous tumor cells. It demonstrated an antitumor immune response in the gene therapy group, but not in the control group. These findings support the concept of in vivo induction of a systemic immune response by local intracerebral HSV-tk/GCV pharmacogene therapy for primary human GBM.

Outcome in Cloward anterior fusion for degenerative cervical spinal disease

The Cloward ventral interbody fusion is often employed for treatment of cervical degenerative disease. The present study was aimed at evaluating results and complications in this classical type of autologous bone graft procedure in a cohort of patients with radiculopathy (RP) or myeloradiculopathy (MRP). Indications for and limitations of the technique were investigated by retrospective data analysis in a series of 106 patients (30 females and 76 males). These underwent single or multiple level Cloward fusion in a total of 145 levels. Neuroradiological investigations included lateral and antero-posterior cervical spine X-rays, axial CT scans, and MRI. The presence of postoperative ossification and stable bony fusion in the fused segments was confirmed by X-rays and, when necessary, by CT. The median postoperative follow-up period was 6.5 years (range 4-10.5 years). Short term outcome in RP patients was good in 26 cases (92.9%) and fair in 2 cases (7.1%). A good short term outcome was seen in 55 MRP patients (70.5%), a fair outcome in 20 patients (25.6%), and a poor outcome in 3 patients (3.8%). Patients having myelopathy signs for less than 1 year had a significantly better outcome than those with clinical signs for more than 1 year (p < 0.05). MRP patients below the age of 40 years had a significantly better outcome than those above the age of 40 (p < 0.05). In the long term, radiculopathy was cured or significantly improved in 92.8% of cases, and myeloradiculopathy in 64%. One year after surgery, there were 139 stably fused segments (96%) and 6 segments showing osseous non-union (4%). Plain lateral radiographs demonstrated, besides the bony fusion in the respective segment, relatively frequent graft collapse with slight to severe correction losses and kyphotic deformity of the cervical spine. However, these findings did not necessarily correlate with the clinical outcome. Autologous bone graft harvesting caused a rather high short-term morbidity with donor site pain and/or wound haematoma in 33% of the cases. These surgery-related complications, however, were of a temporary nature, as long-term complications (cutaneous hypaesthesiae) were found in 2 patients (1.8%) only. In conclusion, Cloward anterior cervical fusion for degenerative spinal disease is a relatively simple and safe surgical procedure with favourable short and long term results. In our hands, graft donor site complications dominate the side effects of surgery, and the percentage of non-unions is rather low. Because of the relatively frequent bone graft collapse and the late loss of postural correction of the spine, we cannot recommend the Cloward type fusion for multisegmental procedures. In such cases, an instrumented plate fusion should be carried out in order to prevent graft collapse and non-union, and to allow for a shorter convalescence period.

Transcranial Doppler sonography in adult hydrocephalic patients

Transcranial Doppler sonography (TCD) is a noninvasive technique for measurement of cerebral blood flow velocity (CBFV) in the major arteries of the circle of Willis. Dynamic changes in the pulsatility index (PI) and the resistance index (RI), as calculated from TCD data, allow for an assessment of the forces acting on the terminal vasculature of the brain. The present study was designed to investigate a possible relationship between TCD parameters and intracranial pressure (ICP) changes in adult patients with hypertensive hydrocephalus. Blood flow velocity in the middle cerebral artery (MCA) was studied by TCD in 29 hydrocephalus patients and in 20 healthy controls. ICP was measured in the patient group before ventricular shunting and was correlated with TCD data. The mean CBFV in hydrocephalic patients prior to ventriculoperitoneal shunting was significantly lower than in the control group. Compared to normal persons, systolic and end-diastolic CBFV values in patients were significantly decreased, suggesting an increased distal cerebrovascular resistance. PI and RI values in patients with elevated ICP prior to shunting were significantly increased in comparison to those of normal persons. There was a statistically significant positive correlation of preshunting ICP and mean preshunting values of RI (r=0.50, P<0.01) in hydrocephalic patients, but no significant correlation between PI and ICP, and between CBFV and ICP. Immediately after shunting, ICP returned to normal, and PI and RI values decreased significantly, while the mean CBFV increased. In a subgroup of hydrocephalic patients with a preshunting ICP value >35 mm Hg (n=6), the changes described above were more pronounced than in the subgroup with preshunting ICP values <35 mm Hg, which suggests an exponential degree of influence of ICP on TCD parameters. In conclusion, TCD may provide a tool for assessment of ICP in adult patients with occlusive hydrocephalus, although an exact noninvasive measurement of ICP by TCD seems impossible. Changes in the RI and PI indices appear to be useful indicators of elevated ICP.

First Light Measurements of Capella with the Low-Energy Transmission Grating Spectrometer aboard the Chandra X-Ray Observatory

We present the first X-ray spectrum obtained by the Low-Energy Transmission Grating Spectrometer (LETGS) aboard the Chandra X-Ray Observatory. The spectrum is of Capella and covers a wavelength range of 5-175 Å (2.5-0.07 keV). The measured wavelength resolution, which is in good agreement with ground calibration, is Deltalambda approximately 0.06 Å (FWHM). Although in-flight calibration of the LETGS is in progress, the high spectral resolution and unique wavelength coverage of the LETGS are well demonstrated by the results from Capella, a coronal source rich in spectral emission lines. While the primary purpose of this Letter is to demonstrate the spectroscopic potential of the LETGS, we also briefly present some preliminary astrophysical results. We discuss plasma parameters derived from line ratios in narrow spectral bands, such as the electron density diagnostics of the He-like triplets of carbon, nitrogen, and oxygen, as well as resonance scattering of the strong Fe xvii line at 15.014 Å.

Is it useful to measure supratentorial ICP in the presence of a posterior fossa lesion? Absence of transtentorial pressure gradients in an animal model

Previous studies with animal models of supratentorial ICP elevation have demonstrated a pressure gradient between the supratentorial and the infratentorial compartments. The present study was designed to investigate the possible presence of such a gradient in the case of infratentorial ICP elevation. An inflatable infratentorial balloon catheter was implanted in seven domestic pigs. The infratentorial ICP (ICPi) was measured in the left cerebellar hemisphere, and the supratentorial ICP (ICPs) was measured in the left cerebral hemisphere. The corresponding pulse amplitudes (ICPi-PA, ICPs-PA) were recorded in both compartments, and the cerebral perfusion pressure (CPP) was calculated. ICPi and ICPs values prior to balloon inflation were 4.4 (SD 2.2) and 4.1 (SD 2.3) mm Hg, respectively, and increased to 63.1 (SD 32.6) and 62.3 (SD 28.1) mmHg after balloon inflation. ICPi-PA rose from 3.1 (SD 0.43) to 12.8 (SD 8.0) mmHg, and ICPs-PA rose from 3.2 (SD 0.63) to 13.0 (SD 7.1) mmHg. CPP decreased from 86.1 (SD 12.0) to 55.4 (SD 14.6) mm Hg. The paired difference between ICPi and ICPs values was 0.44 (SD 1.96) mmHg, and the paired difference of ICP amplitudes was 0.03 (SD 1.19) mmHg. All these differences in infratentorial and supratentorial values were statistically not significant. In conclusion, infratentorial ICP elevation in the presented pig model leads to a uniform ICP elevation in the intracranial space without development of a considerable pressure gradient below and above the tentorium. In the low pressure part of the ICP curve, cerebrospinal fluid connects the compartments and contributes to the pressure equilibrium. The early obstruction of the foramen magnum by intruding cerebellar tissue seems to isolate the infratentorial from the spinal compartment. In the high-pressure part of the curve, the upwards cerebellar transtentorial herniation takes over the pressure transfer, and the whole intracranial space can be considered as a single compartment in the pig.

[Unusual intra-extracranial extension of meningioma of the lateral skull base]

Extracranial meningiomas are rare tumors of the lateral skull base. A 37-year-old woman presented with tinnitus und progressive hearing loss of her right ear. A painful mass lesion was also palpable in her mandibular angle. CT and MRI scans revealed an intracranial mass with extension to the lateral skull base. These findings suggested the occurrence of a paraganglioma or meningioma. In a two-stage surgical procedure tumor was extirpated without functional impairment to the patient. Histology of the excised lesion demonstrated an endotheliomatous meningioma. Since an extracranial meningioma can present as a mass lesion of the lateral skull base, CT and MRI scans are essential in preoperative surgical planning.

Occipito-cervical fusion with the cervical Cotrel-Dubousset rod system

Diseases and conditions which cause instability of the craniocervical junction and the adjacent upper cervical spine are relatively common and potentially life-threatening. Direct internal occipitocervical fusion (OCF) is a modern means of surgical treatment in such cases, and has some advantages over simple immobilization of the affected segments. The present study was designed to evaluate surgical handling, results, and complications with a recently developed instrumentation for OCF, the Cotrel-Dubousset rod-and-hook system (CD). Fourteen consecutive patients with occipito-cervical instability due to fractures, degenerative or neoplastic disease or malformations underwent OCF with the CD system. Autologous or allogeneic bone and bone substitutes such as hydroxyapatite were used to augment the CD fusion. Patients were followed clinically and neuroradiologically for 1 to 4 years (mean 20 months). Assessments were routinely performed at 1 week, 1 month, 3 months, 1/2 year, and every year after surgery. There was no immediate surgery-related morbidity or mortality, and no major late complications due to hardware failure. A stable bony fusion according to radiological criteria was achieved in all cases. No implant breaks or loosening and dislocation of the hooks or the screws were encountered. In no case did neurological deterioration occur after surgery. Short-term evaluation at 1 week after surgery showed no difference with respect to neurological symptoms as compared with the pre-operative findings, except for a patient reporting improvement of paraesthesia on the first postoperative day. The long-term effects were, however, beneficial to most patients, as the fusion alleviated neck pain in 13 cases and improved neurological deficits in 3 of the 4 cases with pre-operative motor weakness or paraesthesia. In conclusion, internal OCF with the CD system, an implant which is easy to handle and safe for the patient, is a technique with a high rate of successful bony fusion. Since no halo placement is needed after surgery, patients have considerable gain of quality of life as compared to other standard surgical techniques.

Anterior cervical fusion with the Orion locking plate system

STUDY DESIGN

This study was conducted to evaluate an anterior cervical fusion plate system, the Orion locking plate, regarding its surgical handling, hardware-related failures, and short-term and long-term results.

OBJECTIVES

A comprehensive evaluation of the implant in a broad range of patients with cervical spine diseases.

SUMMARY OF BACKGROUND DATA

Locking plates are the most recent devices for achieving anterior cervical spinal fusion and offer considerable advantages such as faster and easier implantation and fewer implant-related failures than older plate systems.

METHODS

Ninety-six patients were investigated. All underwent anterior cervical plate fusion as a component of the surgical treatment for symptomatic degenerative cervical spinal disease or for vertebral destruction caused by trauma, tumor, or inflammation. Besides plate fixation, 6 of the 96 patients had a combined ventrodorsal fusion. In 28 cases, one or more vertebral bodies were removed and replaced with titanium place-holders. The remaining 62 patients were first treated by intervertebral inlay placement, and the fused segments were subsequently plated. Neurologic signs and symptoms were evaluated before and after surgery and during a follow-up period of at least 1 year.

RESULTS

The rate of neurologic improvement was highest in radiculopathy patients and lowest in patients with severe myelopathy. In all cases, control radiographs demonstrated a solid bony fusion. Clinical deterioration after surgery was seen in four cases of severe myelopathy in which considerable neurologic deficits existed before surgery, possible because of rapid decompression of the cord and associated microvascular alterations. In two of these cases, there was long-term improvement. Additional general complications caused by surgical retraction included temporary swallowing disturbance in seven patients and a large wound hematoma in one. Hardware failures were encountered in three cases, all of them caused by improper implantation technique and not material failure, per se.

CONCLUSION

In the study group, the Orion locking plate was easy to use, failure-free if properly implanted, safe for the patient and supported solid bony fusion in every case.

Coronally oriented vertical fracture of the axis body: surgical treatment of a rare condition

The neurosurgical management in a rare case of vertical axis fracture is presented along with discussion of the supposed pathogenetic mechanisms and the biomechanics underlying this type of cervical spine injury. Comprehensive neuroradiological investigation prior to surgery clearly demonstrated the dislocation of the anterior part of the axis body with concomitant C 2/C 3-disk injury. Therefore, the unstable fracture had to be managed by a one-time combined ventrodorsal approach using anterior C 2-C 3 locking plate fusion and C 2 bilateral dorsal transpedicular screw fixation. No operative morbidity resulted from this procedure, and stable bony fusion was achieved with minimal restriction of head mobility and with minor residual complaints. This case illustrates the variable biomechanical response of the upper cervical spine to trauma and the advantages of a non-standard surgical approach for internal fixation of the injured cervical spine.

Unusual explanation for the death of a car passenger

After collision of a car with the left rearside against a steel mast the 19-year-old front seat passenger was found comatose on the seat. CT imaging showed a depression fracture parietal on the left with an intracerebral haemorrhage on the opposite side. The cause of the injury was unknown to the surgeons at the time of operation. Despite neurosurgical intervention the patient died 24 h after the accident. The post-mortem showed an additional depression fracture at the base of the skull in the right temporal region arousing suspicion of an impalement injury. Only inspection of the car by the forensic pathologists revealed the gas pressure telescopic shock absorber to be the cause of the head injury.

Dorsal spondylodesis of unstable thoracolumbar fractures by a far-lateral approach to the disc

This paper describes a modified and less traumatic approach to the thoracolumbar spine and compares it with standard techniques for instrumented spinal fusion. Ten patients with unstable fractures of the thoracolumbar spine were included in the open prospective investigation, and were treated by a surgical technique consisting of a dorsolateral approach to the injured segment, filling the disk space and the fractured vertebra with autologous bone, and transpedicular fixation with an AO internal fixator. All patients were followed for 6 to 12 months after surgery by clinical tests and spinal X-rays. Excellent short-term and long-term results were obtained. A stable bony fusion was achieved in all cases, and a minimal mean decrease of 2 degrees in the kyphosis angle was found at late follow-up. No major complications related to the procedure were encountered, and no worsening of neurological deficits occurred after surgery. In conclusion, the far-lateral approach to the thoracolumbar spine yields results which are equivalent or better than those of standard techniques. Major advantages of our procedure, as evaluated in this rather small group of patients, are selective immobilization of the injured segment without involvement of functionally intact spinal levels, no manipulations within the spinal canal boundaries, and relatively limited exposure of the spine.

[Thromboembolic complications in neurosurgical patients]

This study was aimed at the analysis of thromboembolic risk factors in a large and representative group of adult neurosurgical patients. Using an open retrospectively designed mode of evaluation, 3162 inpatients treated in 5 years were investigated. Thromboembolism was diagnosed clinically and confirmed be ultrasound and phlebographic tests. Thromboembolism prophylaxis included subcutaneous injection of low-molecular-weight heparin and supporting physical therapy. In the whole patient population, 2.6% deep venous thromboses and 0.7% fulminant pulmonary embolisms were diagnosed. Risk factors such as malignant disease, ischemic disease of the heart, history of thromboembolism, age over 60 years, varicosis, and immobilisation rendered patients especially prone to thromboembolic events, increasing 2- to 3-fold their respective risk and reaching for some factors the level of statistical significance. Low-molecular-weight heparin application reduced the rate of thromboembolic complications, as compared to the group without heparin prophylaxis. Wound revision because of hematoma formation was necessary in 1.1% of all cases, and heparin did not induce an increase in the rate of wound hematoma formation. We conclude that low-molecular-weight heparin prophylaxis is able to safely reduce the rate of thromboembolic events in neurosurgical patients without producing additional drug-related surgical complications.

Prognostic factors in malignant glioma: influence of the overexpression of oncogene and tumor-suppressor gene products on survival

Despite the use of multimodal therapy, higher-grade glioma is still uniformly fatal in the adult population. There is a considerable difference between the length of survival in each given patient, even within the same tumor type and malignancy grade group, suggesting that there are factors that might differentially influence outcome. To identify such factors, 107 patients with anaplastic or malignant glioma were retrospectively investigated. Clinical parameters and paraclinical data on the p53, mdm2, and EGFR genes at the DNA or protein level were evaluated by univariate analysis and Cox proportional hazards regression modeling. Kaplan-Meier survival estimation demonstrated that immunohistochemical positivity for mdm2 protein in patients with anaplastic astrocytoma or with glioblastoma multiforme was associated with a shorter survival time (p = 0.02). P53 gene mutations and immunopositivity for the epidermal growth factor receptor (EGFR) protein were not significantly related to poor prognosis. The Cox proportional hazards model revealed immunohistochemical positivity for p53, mdm2, or for both of them, the presence of postoperative irradiation, and the extent of surgical resection of tumor to be variables significantly associated with prolonged survival. EGFR overexpression, age over 60 years, and Karnofsky performance score below 40 points did not significantly shorten survival time. In conclusion, the present study identified immunohistochemically detected mdm2-protein overexpression as a statistically significant negative prognostic parameter in patients bearing anaplastic or malignant glioma. Association analysis of variables revealed a possible correlation between mdm2 and p53, which is also consistent with the biological interaction mode of both proteins in vivo.

Factors predicting pituitary adenoma invasiveness in acromegalic patients

Forty-four adult acromegalic patients carrying growth hormone-producing pituitary macroadenomas were investigated with neuroradiological and endocrinological techniques. Plasma growth hormone and somatomedin-C levels were repeatedly measured before surgical removal of tumors and during the follow-up period. Twenty-five patients presented preoperatively with an invasive adenoma that involved the cavernous sinus (CS). Diagnosis of tumor invasivity was made according to distinct neuroradiological criteria and was confirmed or rejected during surgery Significantly higher basal growth hormone levels were found in patients with CS invasion than in cases without tumor growth in the CS. Evidence is presented that plasma growth hormone level in acromegalics is a more sensitive indicator for predicting tumor invasiveness than somatomedin-C. Growth hormone basal values before surgery and the extent of their decrease after removal of tumor correlate with adenoma growth in the parasellar compartments and should be used as a prognostic factor to aid in planing adjuvant tumor treatment.

Continuous monitoring of the partial pressure of oxygen in cerebral venous blood

OBJECTIVE

Clinical oxygen monitoring in the injured brain is somewhat difficult. However, ischemia is one of the major factors responsible for secondary tissue damage after head injury or subarachnoid hemorrhage. Therefore, the aim of the present study was to investigate the value of continuously monitoring the partial pressure of oxygen in cerebral venous blood (PcvO2) during changes in intracranial pressure (ICP).

METHODS

In eight domestic pigs with Clark type probes placed in the posterior third of the superior sagittal sinus, PcvO2 was continuously registered while ICP was stepwise elevated by an inflatable balloon placed below the tentorium. Arterial blood pressure was continuously monitored, cerebral perfusion pressure (CPP) was calculated, and arterial partial carbon dioxide pressure and partial pressure of oxygen were registered intermittently.

RESULTS

The mean intraparenchymal ICP before the start of balloon inflation was 5 +/- 1 mm Hg, the mean CPP was 80 +/- 15 mm Hg, and the mean PcvO2 was 36 +/- 3 mm Hg. At maximum ICP elevation, CPP decreased to 20 +/- 12 mm Hg, PcvO2 decreased to 10 +/- 6 mm Hg, and ICP increased to 90 +/- 10 mm Hg. Strong linear correlations between ICP and PcvO2 and between CPP and PcvO2 were revealed, and mean correlation coefficients of 0.89 for ICP/PcvO2 and 0.73 for CPP/PcvO2 were calculated.

CONCLUSION

The present study demonstrates that polarographic PcvO2 monitoring in the superior sagittal sinus is a reliable method for the early detection of reduced CPP during ICP elevation. This technique is capable of registering the global oxygen supply and oxygen consumption of the brain. It seems superior to jugular venous oxymetry and is better suited for clinical use because of a somewhat low artifact susceptibility.

Epidural electrical stimulation of the motor cortex in patients with facial neuralgia

Chronic facial neuralgias often do not respond sufficiently to standard treatment methods. Alternative modalities are needed for long-term reduction of pain in such cases. The present preliminary report describes two patients with trigeminal and glossopharyngeal neuralgia, respectively, treated with standard methods without obtaining satisfactory pain relief. Electrical stimulation of the motor cortex contralateral to the pain area was employed in both cases and proved able to produce a long-term facial pain reduction. Alleviation of pain occurred after activation of the flat quadripolar electrode placed epidurally on the precentral cortical area and lasted as long as the stimulator was working. By changing the polarity of the electrodes, it was possible to induce tingling sensations and muscle activation not only contralaterally to the stimulated motor cortex, but also in the ipsilateral part of the face. No stimulator-independent pain reduction resulted from long-term use of the stimulation device. During a follow-up period of 18 months, a sufficient and relatively stable analgesic effect of electrostimulation was observed. One major complication of motor cortex stimulation during the follow-up period was a single generalized epileptic seizure in one of the patients.

[Continuous measurement of jugular venous blood gas. A case of subarachnoid bleeding]

INTRODUCTION

Recently, a compact multisensor device 0.5 mm in diameter has become available with a miniaturised Clark electrode for measuring blood oxygen tension and two optical fibres for measuring CO2 tension, pH, and temperature (Paratrend 7, Biomedical Sensors, High Wycombe, UK). We used this new probe for continuous blood gas monitoring in the jugular bulb as an alternative to the commonly used fiberoptic spectrophotometric oximetric measurement of haemoglobin saturation.

RESULTS

A 64-year-old patient was admitted for surgery of a right-sided intracranial aneurysm. During surgery, with no artefacts or evidence of catheter drift, a normal jugular venous pO2 (pjvO2) of 39 +/- 3 mmHg was measured. Over the period of weaning, two declines in pjvO2 occurred (22.5 and 18.7 mm Hg) associated with a decline in CO2 tension and a rise in pH. We treated these events successfully by analgosedation, controlled ventilation with an inspired oxygen fraction of 70%, and elevation of the mean arterial blood pressure to over 100 mmHg. Extubation was possible about 24 h later. Furthermore, 3 h after extubation pjvO2 values could be monitored without difficulty despite movement of the patient.

DISCUSSION

The technique of polarographically measuring pjvO2 with a Clark-type probe appears superior to fibreoptic jugular venous oximetry due to the clearly lower incidence of faulty measurements, especially in the intensive care unit, where patients undergo frequent nursing interventions and tend to awaken. We did not even observe artefacts due to patient movement after extubation. A limitation of the new multisensor system might be the distance of 4 cm between the sensor tip and the end of the insertion catheter, which makes samples drawn for in vitro blood gas analyses to control the continuous monitoring less comparable. Improvements in the construction of the probe are recommended.

[Cerebrovascular fiberoptic catheter oximetry in an intracranial pressure model in swine. New aspects of a clinical routine]

The reliability of continuous fibreoptic oximetry in cerebral venous blood and its correlation with intracranial and cerebral perfusion pressures (pressure-volume curve) were examined in an experimental porcine study.

METHODS

The pressure in the infratentorial compartment of 13 domestic pigs (18-24 kg) was gradually increased by inflating a Fogarty balloon catheter placed on the surface of the right cerebellar hemisphere and below the tentorium. Single volumes of 0.4 ml saline were injected into the inflatable balloon at 1-min intervals up to a total volume of 7 ml. Intracranial pressure (ICP), arterial blood pressure, cerebral perfusion pressure (CPP), and cerebral venous saturation measured continuously by fibreoptic oximetry and intermittent blood-gas analyses (SjO2 superior sagittal sinus) were monitored during balloon inflation. All data were down-loaded onto a PC and evaluated off-line by a commercial statistical software package.

RESULTS

Over the whole pressure-volume curve, two phases of SjO2 behaviour were registered by continuous fibreoptic oximetry (Oximetrix 3, Abbott) (Fig. 1). CPP ranges of less than 50% reduction from the initial value showed a linear correlation (rmittl. = 0.712, P < 0.01) between both parameters (CPP-SjO2). In CPP ranges below a crucial point of about 50 mmHg no such correlation was found (rmittl = 0.176, P < 0.5). In contrast, in 3 pigs a very good correlation was found between CPP and SjO2 over the whole pressure-volume curve as measured by blood-gas analyses of samples from the cerebrovenous catheter (rmittl. = 0.84, P < 0.05).

DISCUSSION

We conclude that in physiological CPP ranges down to 50 mmHg, SjO2 measurement is a reliable method of detecting oxygen desaturation in cerebrovenous blood. Below that CPP value, the fibreoptic catheter showed repeated false-high oxygen saturation values. The accuracy of SjO2 measurement seems to depend on sufficient cerebral blood flow (CBF): with decreasing CBF the amount of cerebral venous outflow is diminished. We believe this is why we could not find a correlation in low CPP ranges with the oximetry catheter. This flow-dependency is a new aspect of fibreoptic cerebrovenous oximetry. The authors recommend that rising SjO2 values after desaturation events be confirmed by blood-gas analyses.

Somatostatin receptor scintigraphy in patients with pituitary adenoma

Presence of high-affinity somatostatin (SST) receptors in most endocrine tumor cells allow in vivo scintigraphic visualization of these neoplasms after intravenous administration of a radionuclide-labeled somatostatin analog. 111In-octreotide is at present the most often used substance for imaging of the SST receptor expression in vivo. The aim of this study is to investigate the correlation between presence of in vivo scintigraphically detectable SST receptors in pituitary tumors and clinical parameters such as patients' age, tumor size, hormonal hypersecretion, and response to octreotide therapy. Forty-two-consecutive patients were enrolled in this trial. Twenty-five of them had nonsecreting pituitary tumors, 11 were acromegalic, and 6 had macro- or microprolactinoma. Scintigraphic images of the head were obtained at 10 min and 24 hours after injection of the radionuclide. In 23 patients, no specific binding of 111In-octreotide was found. Five patients showed a weak positive, 5 had a positive, and 9 a strong positive signal in the region of interest. Uptake of octreotide was significantly correlated with tumor size and age (p < 0.01). Small-size pituitary adenomas were most likely to be scintigraphically receptor-negative, while large suprasellar tumors tended to exhibit a rather strong receptor positivity. Statistical analysis of the data could not confirm the hypothesized correlation between endocrine activity of the pituitary tumors and the scintigraphically proven SST receptor expression in vivo. A positive Octreoscan was not predictive for the result of octreotide therapy.

Back to the roots of modern neurosurgery: neurosurgical pioneers in Halle an der Saale

At the end of the 19th and the beginning of the 20th centuries, German surgeons played a large role in the development of neurologic surgery. Many of them, however, have not been fully appreciated by the neurosurgical community until now. Pioneering personalities like F. Krause and F. von Bramann have contributed considerably to the early establishment of standard neurosurgical principles and operative techniques. Alexander Stieda was their successor and kept alive the neurosurgical tradition in Halle until the end of World War II. This middle-sized city in Central Germany, with an old university where Martin Luther once taught, was especially privileged to be one of the places where some of the best-qualified and restless surgeons have practiced neurologic surgery and done work in progress. This paper traces the biographies of the great old masters of German neurosurgery in search of the "Halle connection" to the progress of our field.

Short test-period spinal cord stimulation for failed back surgery syndrome

The aim of this study was to investigate the effects of spinal cord stimulation (SCS) on patients with chronic pain due to failed back surgery syndrome and to evaluate selection criteria for predicting SCS success. Thirty-two patients were enrolled in the present study. Prior to test implantation, all of them have been screened with various plan questionnaires and were selected for the SCS procedure according to stringent criteria. The single-electrode neurostimulators Itrel II and Xtrel were used with percutaneously inserted leads. The leads were placed under X-ray image intensifier control, and position was modified until optimum paresthetic coverage of pain areas was achieved. Twenty-nine of the 32 test stimulation patients reported on a pain reduction of at least 50% and up to 90% of preimplantation values. After a test period of 24 to 72 hours, internalization of the whole SCS system followed. In 3 cases the lead was explanted after 3 days of test stimulation because of insufficient analgesic effect. No major complications were seen in this highly preselected group. Follow-ups of 2 to 3.5 years after lead implantation proved stable analgesia and good outcome in 25 patients. Further 4 patients experienced a late failure of the system due to decreased analgesic effects of SCS. In conclusion, if the selection of SCS candidate patients is performed very carefully and according to well defined criteria, test stimulation periods can be kept relatively short, thus reducing therapeutic failures, risk of infection, and costs of therapy.

Ultrasound-guided endoscopic fenestration of the third ventricular floor for non-communicating hydrocephalus

Conventional valve shunting for treatment of hydrocephalus has a high rate of long-term complications. Endoscopic ventriculostomy by fenestration of the third ventricular floor, a minimally-invasive technique, avoids many of the drawbacks of extracranial shunting. Endoscopy was performed in 12 hydrocephalic patients with MRI-diagnosed aqueductal stenosis and neurological signs. Intraoperative ultrasound guidance allowed aiming the tip of the rigid endoscope to the foramen of Monro, and direct entering of the enlarged third ventricle. This technique is as exact as stereotaxy but is faster and easier. No complications were seen due to the surgical procedure. Nine patients were cured from their complaints, in 3 cases there was a subjective improvement of neurology. Long-term patency of the third ventriculostomy was confirmed by movement-sensitive MRI.

Direct anterior fixation of odontoid fractures with a hollow spreading screw system

Direct fixation of odontoid fractures has the advantage of preserving rotation in the atlanto-axial motion segment. Early mobilisation of patients and minor intra-operative trauma increase the value of this technique. The original screw method of Nakanishi, Magerl, and Böhler, was improved by Knöringer who designed a double-threaded screw for direct fixation of dens axis fractures. He stated that double screwing is absolutely necessary in order to prevent rotation of fragments against each other. The purpose of the present study was to describe a new single screw for direct fixation of odontoid fractures, which is easy to place into the limited space of the dens axis and which offers enough rotational stability and sufficient compression of fracture fragments. The so-called hollow spreading screw system (HSS) consists of an outer hollow screw, a spreading insert, a toothed washer, an hexagonal nut, and a protective nut. Thirty-five patients with traumatic and arthritic odontoid fractures were treated using direct internal fixation with the HSS system. In 30 cases, there was a type-II-fracture, in 3 a shallow type-III-fracture, and in 2 a type-II-fracture with pseudarthrosis formation. Pre-operative neurological deficits were seen in 16 cases. No additional neurological deficits were caused by the surgical procedure. The bony fusion rate of fresh fractures in the presented series was 100%. With the HSS system, ca. 12% postoperative complications, such as slight reduction of head rotation or neck pain, were found. These results are virtually equal to the results of the double-screw technique. Since a relatively simple technical procedure is required for placement of the screw, the HSS system can be recommended in all cases of odontoid fractures suitable for direct anterior fixation.

Local invasivity of glioblastoma multiforme with destruction of skull bone. Case report and review of the literature

Primary tumors originating from cells of the glial lineage usually affect predominantly the white matter of the brain. Only rarely do gliomas destroy the surrounding bone by invasion of the extracellular matrix, especially without prior surgery. This paper describes the unusual case of a 66-year-old female patient with a left-sided intra- and extracranial tumor involving the temporal lobe, destroying the underlying skull base, and growing into the paranasal sinuses, orbit, and temporal bone. Biopsy revealed glioblastoma multiforme with strong GFAP positivity. Molecular biologic investigations of the p53, EGFR, and mdm2 genes showed functional inactivation of the p53 gene but no overexpression of oncogenes. Because the tumor was considered inoperable, palliative irradiation was carried out. The patient died 7 months after diagnosis. The causes of this phenomenon are discussed and the literature reviewed.

Intra-operative epidural morphine, fentanyl, and droperidol for control of pain after spinal surgery. A prospective, randomized, placebo-controlled, and double-blind trial

The present study was conducted to investigate the analgesic effects of intra-operatively administered epidural morphine in patients undergoing surgery for lumbar disc disease. Three treatment groups were constituted: one with 5.0 mg morphine and 2.5 mg dehydrobenzperidol (DHB) in 10 ml physiological saline, one with 5.0 mg morphine and 0.1 mg fentanyl in the same amount of saline, and one placebo group with saline only. The test solution was injected epidurally via catheter after haemostasis and before closure of the wound. Sixty eight patients were randomly assigned to each of the three groups and subjected to a double-blind evaluation. In the morphine/fentanyl and morphine/droperidol groups, significantly better analgesia was found as compared to the placebo group. No significant difference was found between the morphine/fentanyl and morphine/droperidol groups considering side effects of therapy, as well as duration and quality of analgesia. The side effects in the treatment groups were only slight and not significantly different from the placebo group. It was shown that additional epidural fentanyl offers no significant improvement of postoperative analgesia. No significant reduction of adverse effects could be found in the morphine/droperidol group compared to the morphine/fentanyl group. In conclusion, the intra-operative epidural application of morphine is a safe, effective and simple method for achieving sufficient analgesia in the first 24 hours after lumbar spinal surgery for disc disease.

The X-Ray CCDs Developed for the Joint European X-Ray Telescope

The charge coupled devices (CCDs) developed for the Joint European X-ray Telescope (JET-X) are described in detail. A history of the development program and device performance is given. We present results from a comprehensive study to characterize the x-ray response of the flight model focal plane detectors. The goal of the program is to calibrate the efficiency, energy resolution, gain, etc. down to a precision of ~1%. Final calibration data sets will be based on combinations of measurements and calculations. For example, the CCD quantum efficiency will be composed of discrete line measurements made at the University of Leicester test facility and calculation and synchrotron measurements from the Daresbury Synchrotron Radiation Source (SRS). The absolute normalizations will be provided by x-ray long beam pipe measurements at the Max Planck Institut für Extraterrestrische Physik (MPE) Panter test facility in Munich. Using the available data, it is shown that it is possible to calibrate the quantum efficiency, the FWHM energy resolution, and the system gain of the flight devices to better than 1%.

Absence of p53 autoantibodies in sera from glioma patients

Alteration of the tumor suppressor gene p53 is the most frequent genetic feature of human cancer and leads to over-expression and loss of function of the p53 protein in affected cells. Patients with many types of cancer, including breast, lung, and colon carcinoma, were shown to develop auto-immune response against the overexpressed protein and to produce autoantibodies directed to immunodominant epitopes common for both wild type and mutants. The presence of p53 autoantibodies (p53-aAb) seems to be, at least in patients with breast and bronchial tumors, related to an unfavorable prognosis. The present study aimed to investigate the presence of p53-aAb in patients with malignant glioma. Sera from 70 consecutive patients with gliomas graded WHO G III and IV were collected and assayed together with sera from 30 controls. A new photometric sandwich-ELISA was used for semiquantitative analysis of p53-aAb titers. p53 gene and its protein product were examined in formalin-fixed and fresh-frozen tumor tissues using immunohistochemistry, PCR-single-strand conformational polymorphism, and sequencing. Sixty percent of the glioma cases showed immunohistochemically positive cells, thus indicating intracellular accumulation of p53. Sequencing of the hot-spot exons 5-8 revealed mutations in 39% of the tumor cases. In contrast to results in other types of malignant tumors, where up to 40% of patients have high serum titers of p53-aAb, no such antibodies were found in patients with malignant cerebral glioma despite the presence of mutated or alterated p53 protein in the primary tumors. None of the non-cancer control patients had detectable titers of p53-aAb, although sera from five of six lung cancer patients had medium to high titers. The presented data suggest that glial tumors are unusual in the absence of serum antibodies to p53. It is hypothesized that impaired function of most immunocompetent cells invading brain tumors could be the cause for the absence of an autoimmune response.

Dysplastic gangliocytoma of the cerebellum (Lhermitte-Duclos disease)

The case of a 30-year-old male patient is presented who was admitted with a 3-month history of elevated intracranial pressure and reduced-hearing on the right. CT revealed hydrocephalus due to displacement of the 4th ventricle by a large non-enhancing cerebellar mass with calcifications. MRI sequences showed a space-occupying lesion within the right cerebellar hemisphere with unusual septations. At operation, the poorly demarcated lesion was excised from the apparently normal surrounding cerebellar tissue and histologically proven to be a dysplastic gangliocytoma (Lhermitte-Duclos disease). Clinical and neuroradiological appearance of this rare entity, as well as hypotheses on its pathogenesis are discussed.

Thoracic and lumbar meningocele in neurofibromatosis type 1. Report of two cases and review of the literature

We report two cases of ventrolateral thoracic and lumbar meningoceles associated with neurofibromatosis type 1, and present a review of the literature. Thoracic and lumbar meningoceles are rare lesions which are associated with neurofibromatosis in 60% to 85% of cases. Large meningoceles may cause pain, neurological signs, or respiratory complaints when located intrathoracically. Surgery is indicated in such cases, as well as when small meningoceles enlarge with time. The etiology of meningoceles in neurofibromatosis remains controversial. The authors postulate that ventrolateral lesions of the thoracic and lumbar spine are secondary to congenital mesodermal dysplasia and hypoplastic bone changes. MRI is the diagnostic method of choice, since it most adequately visualizes the pathological anatomy of the spinal cord, meninges, and adjacent structures in every sectional plane. CT scans are particularly useful in assessing the spinal bony changes.

Complete disappearance of giant intracranial germinoma after irradiation

Intracranial germinomas are lesions with a varying, rather benign growth potential, and account for only 0.3 to 1.5% of all brain tumors. About 70% of the patients with these tumors are between 10 and 21 years of age at diagnosis. Germinomas are radiosensitive and respond well also to chemotherapy. The case of a 22-year-old male patient with a giant primary intracranial germinoma originating in the pineal region is presented. Clinical signs and symptoms are described together with neuroradiological, light-microscopic, and immunohistochemical findings. The tumor was irradiated with a total dose of 46 Gy and disappeared completely already after an effective tumor dose of 30 Gy. No recurrence was seen during a follow-up of three years. The patient's quality of life could be preserved and a complete cure was achieved.

Abdominal CSF pseudocysts in patients with ventriculo-peritoneal shunts. Report of fourteen cases and review of the literature

The abdominal intraperitoneal cerebrospinal fluid pseudocyst is an infrequent but important complication in patients with ventriculoperitoneal shunts. Since 1954, 115 cases of paediatric pseudocysts have been reported in the literature. One additional report deals with an adult patient. We report on 14 cases of sonographically diagnosed abdominal pseudocysts. Their aetiology, diagnosis, clinical signs and symptoms and surgical management are investigated. In our hydrocephalus series we have an incidence of pseudocyst formation of 4.5%. The most common presentation of the paediatric patients is with symptoms of elevated intracranial pressure and abdominal pain, whereas the adults have predominantly local abdominal signs. Diagnosis is readily made with ultrasonography. Predisposing factors for pseudocyst formation are multiple shunt revisions and infection. Microscopically, the pseudocysts consist of fibrous tissue without epithelial lining. The treatment involves surgical removal of the catheter with or without excision of the pseudocyst wall and placement of a new catheter intraperitoneally in a different quadrant or an intra-atrial shunt. Recurrences are rare, especially under appropriate medical treatment of infection. In our series, microbiologically proven infection was present in 30% of the cases.

Malignant growth of a recurrent macroprolactinoma after radiation therapy

The authors report a case of a 60-year-old woman with a macroprolactinoma. After radiation therapy of the subtotally excised recurrent tumor, it developed a rapid malignant-destructive growth with invasion into adjacent structures. The causal factors are discussed and the literature is briefly reviewed.

Spontaneous shrinking of a macroprolactinoma

The case of a male patient with a macroprolactinoma is presented. Within a follow up period of six months the tumor had spontaneously shrunken without any therapy. The causes of this phenomenon are discussed in the following paper.

Grazing incidence replica optics for astronomical and laboratory applications

Replica technology was developed for manufacturing numerous low-cost grazing incidence x-ray mirrors for both laboratory and astrophysical experiments. About forty mirrors with apertures between 1.7 and 24 cm have so far been made. The results of tests both at optical and x-ray wavelengths indicate that replica optics is well suited for space and laboratory uses.

Optics for the x-ray imaging concentrators aboard the x-ray astronomy satellite SAX

The scientific instrumentation onboard the Italian satellite for x-ray astronomy (SAX) foresees x-ray imaging concentrators operating in the 0.1-10-keV energy range with a spatial resolution of 1 min of arc. The optics is composed of thirty confocal-nested very thin double-cone mirrors. To achieve good optical quality and to allow the construction of several concentrators at an acceptable cost, a replica technique by electroforming the mirrors from masters is used. This paper presents the results obtained from a set of electroformed mirrors mounted on a concentrator prototype.

[Effectiveness of cimetidine in the prevention of aspiration pneumonia in obstetrics]

In a prospective controlled study 30 parturients provided for elective cesarean section were premedicated either with no specific medication for prophylaxis of aspiration pneumonia or 400 mg cimetidine orally at the evening and 400 mg intramuscularly two hours prior to induction of anesthesia. In the cimetidine treated group only one patient had a gastric pH below 2.5, while in the control group 11 patients had a pH below this limit. The gastric volume in the cimetidine treated group also was significantly reduced. No side effects could be observed in mothers and children. Application of intramuscularly cimetidine seems to be an effective method for prophylaxis of aspiration pneumonia in obstetric anesthesia.

[Pregnancy and immune system. I. Immunological characterization of mononuclear cells during late pregnancy (author's transl)]

Lymphocyte preparations obtained from peripheral blood of 36 healthy pregnancy women during the last 4 weeks of gestation were tested for various cell surface markers (E-, EA- EAC-rosettes, surface Ig positive cells). 29 healthy, non-pregnant age matched women served as controls. The cell surface marker analysis did not show significantly different results in the two groups tested except diminished percentages of EA-rosettes in the pregnancy group. EA-rosettes-forming cells (Fc-receptor positive cells) are known to the effectors of spontaneous and antibody dependent lymphocytotoxicity. Therefore, slightly depressed lymphocytotoxicity may be expected during late pregnancy.

[Determination of blood coagulation in acute obstetrical and gynecologic hemorrhages by means of the Hellige direct writing thrombelastograph]

Thrombelastography, as a method of rapid registration, is an important addition to the present screening tests of coagulation status. With this method we are able to quickly obtain exact values for clotting and fibrinolysis with more precision than those which can be obtained from the clot observation test. The TEG monitor must however be available in the immediate vicinity of the labour ward and must be ready for use around the clock. Specific therapy for the elimination of failures in hemostasis may then be started without delay, due to prompt determination of coagulation status and early detection of fibrinolysis.