Integration of radiation oncology teaching in medical studies by German medical faculties due to the new licensing regulations : An overview and recommendations of the consortium academic radiation oncology of the German Society for Radiation Oncology (DEGRO).

The new Medical Licensing Regulations 2025 (Ärztliche Approbationsordnung, ÄApprO) will soon be passed by the Federal Council (Bundesrat) and will be implemented step by step by the individual faculties in the coming months. The further development of medical studies essentially involves an orientation from fact-based to competence-based learning and focuses on practical, longitudinal and interdisciplinary training. Radiation oncology and radiation therapy are important components of therapeutic oncology and are of great importance for public health, both clinically and epidemiologically, and therefore should be given appropriate attention in medical education. This report is based on a recent survey on the current state of radiation therapy teaching at university hospitals in Germany as well as the contents of the National Competence Based Learning Objectives Catalogue for Medicine 2.0 (Nationaler Kompetenzbasierter Lernzielkatalog Medizin 2.0, NKLM) and the closely related Subject Catalogue (Gegenstandskatalog, GK) of the Institute for Medical and Pharmaceutical Examination Questions (Institut für Medizinische und Pharmazeutische Prüfungsfragen, IMPP). The current recommendations of the German Society for Radiation Oncology (Deutsche Gesellschaft für Radioonkologie, DEGRO) regarding topics, scope and rationale for the establishment of radiation oncology teaching at the respective faculties are also included.

Prognostic impact of gross tumor volume during radical radiochemotherapy of locally advanced non-small cell lung cancer-results from the NCT03055715 multicenter cohort study of the Young DEGRO Trial Group.

BACKGROUND: In radical radiochemotherapy (RCT) of inoperable non-small-cell lung cancer (NSCLC) typical prognostic factors include T- and N-stage, while there are still conflicting data on the prognostic relevance of gross tumor volume (GTV) and particularly its changes during RCT. The NCT03055715 study of the Young DEGRO working group of the German Society of Radiation Oncology (DEGRO) evaluated the prognostic impact of GTV and its changes during RCT. METHODS: A total of 21 university centers for radiation oncology from five different European countries (Germany, Switzerland, Spain, Belgium, and Austria) participated in the study which evaluated n = 347 patients with confirmed (biopsy) inoperable NSCLC in UICC stage III A/B who received radical curative-intent RCT between 2010 and 2013. Patient and disease data were collected anonymously via electronic case report forms and entered into the multi-institutional RadPlanBio platform for central data analysis. GTV before RCT (initial planning CT, GTV1) and at 40-50 Gy (re-planning CT for radiation boost, GTV2) was delineated. Absolute GTV before/during RCT and relative GTV changes were correlated with overall survival as the primary endpoint. Hazard ratios (HR) of survival analysis were estimated by means of adjusted Cox regression models. RESULTS: GTV1 was found to have a mean of 154.4 ml (95%CI: 1.5-877) and GTV2 of 106.2 ml (95% CI: 0.5-589.5), resulting in an estimated reduction of 48.2 ml (p < 0.001). Median overall survival (OS) was 18.8 months with a median of 22.1, 20.9, and 12.6 months for patients with high, intermediate, and low GTV before RT. Considering all patients, in one survival model of overall mortality, GTV2 (2.75 (1.12-6.75, p = 0.03) was found to be a stronger survival predictor than GTV1 (1.34 (0.9-2, p > 0.05). In patients with available data on both GTV1 and GTV2, absolute GTV1 before RT was not significantly associated with survival (HR 0-69, 0.32-1.49, p > 0.05) but GTV2 significantly predicted OS in a model adjusted for age, T stage, and chemotherapy, with an HR of 3.7 (1.01-13.53, p = 0.04) per 300 ml. The absolute decrease from GTV1 to GTV2 was correlated to survival, where every decrease by 50 ml reduced the HR by 0.8 (CI 0.64-0.99, p = 0.04). There was no evidence for a survival effect of the relative change between GTV1 and GTV2. CONCLUSION: Our results indicate that independently of T stage, the re-planning GTV during RCT is a significant and superior survival predictor compared to baseline GTV before RT. Patients with a high absolute (rather than relative) change in GTV during RT show a superior survival outcome after RCT.

Radiation treatment of hemato-oncological patients in times of the COVID-19 pandemic : Expert recommendations from the radiation oncology panels of the German Hodgkin Study Group and the German Lymphoma Alliance.

PURPOSE: The coronavirus pandemic is affecting global health systems, endangering daily patient care. Hemato-oncological patients are particularly vulnerable to infection, requiring decisive recommendations on treatment and triage. The aim of this survey amongst experts on radiation therapy (RT) for lymphoma and leukemia is to delineate typical clinical scenarios and to provide counsel for high-quality care. METHODS: A multi-item questionnaire containing multiple-choice and free-text questions was developed in a peer-reviewed process and sent to members of the radiation oncology panels of the German Hodgkin Study Group and the German Lymphoma Alliance. Answers were assessed online and analyzed centrally. RESULTS: Omission of RT was only considered in a minority of cases if alternative treatment options were available. Hypofractionated regimens and reduced dosages may be used for indolent lymphoma and fractures due to multiple myeloma. Overall, there was a tendency to shorten RT rather than to postpone or omit it. Even in case of critical resource shortage, panelists agreed to start emergency RT for typical indications (intracranial pressure, spinal compression, superior vena cava syndrome) within 24 h. Possible criteria to consider for patient triage are the availability of (systemic) options, the underlying disease dynamic, and the treatment rationale (curative/palliative). CONCLUSION: RT for hemato-oncological patients receives high-priority and should be maintained even in later stages of the pandemic. Hypofractionation and shortened treatment schedules are feasible options for well-defined constellations, but have to be discussed in the clinical context.

Quality of teaching radiation oncology in Germany-where do we stand? : Results from a 2019 survey performed by the working group "young DEGRO" of the German Society of Radiation Oncology.

PURPOSE: Medical students' knowledge of radiation oncology (RO) is of increasing importance with a rising prevalence of malignancies. However, RO teaching in medical schools is heterogeneous and has not been analyzed at a federal level yet. Therefore, the following survey aims to provide a national overview of RO teaching in Germany. METHODS: A questionnaire containing multiple-choice and free-text questions covering the extent and topics of RO teaching was sent to RO departments of all university hospitals in Germany and was answered by the heads of department/main lecturers. RESULTS: 24/35 (68.6%) RO departments returned completed forms. Most faculties employ lectures (91.7%), seminars (87.5%), and practical/bedside training (75.0%), whereas training in radiation biology and medical physics are rare (25% and 33.3%, respectively). Main topics covered are general RO (100%), radiation biology (91.7%), and side effects (87.5%). Regarding RO techniques and concepts, image-guided and intensity-modulated radiotherapy are taught at all faculties, followed by palliative and stereotactic techniques (87.5% each). Notably, all departments offered at least a partial rotation in RO in conjunction with radiology and/or nuclear medicine departments in the last year of medical school, while only 70.8% provided a complete rotation in RO. In addition, 57.1% of the departments have taken measures concerning the upcoming National Competence-Based Learning Objectives Catalogue (NKLM) for medical education. CONCLUSION: RO plays an integral but underrepresented role in clinical medical education in Germany, but faces new challenges in the development of practical and competence-based education, which will require further innovative and interdisciplinary concepts.

Re-irradiation for recurrent glioblastoma multiforme: a critical comparison of different concepts.

PURPOSE: Purpose of this study was to investigate outcome and toxicity of re-irradiation for recurrent primary glioblastoma (rGBM). We evaluated a group of patients with rGBM and identical primary treatment comprising adjuvant radiotherapy (30â€¯× 2 Gy) with concurrent temozolomide (TMZ). METHODS: In this retrospective study of 46 patients, all received adjuvant or definitive normofractionated radiotherapy to a pretreated area, some with concurrent chemotherapy. Impact of different clinical, histological, or epidemiological factors on survival and radiation toxicity was reviewed. RESULTS: Of 46 patients, 40 completed the intended therapy. Overall survival (OS) was 20 months (range 6-72 months). Overall survival and progression-free survival after re-irradiation (OS2 and PFS2) were 9.5 and 3.4 months (range 2-40 and 0.7-44 months). Simultaneous systemic therapy improved PFS2 and OS2 (4.3 vs. 2.0, p < 0.001 and 12 vs. 4 months, p = 0.13, respectively). Therapy with TMZ or bevacizumab improved PFS2 vs. nitrosureas (6.6 vs. 2.9, p = 0.03 and 5.1 vs. 2.9 months, p = 0.035, respectively). TMZ also improved PFS2 and OS2 vs. all other systemic therapies (6.6 vs. 4, p < 0.001 and 17 vs. 10 months, p = 0.1). In a subgroup analysis for patients with methylation of the MGMT promoter, doses of >36 Gy as well as TMZ vs. no systemic therapy improved PFS2 (p = 0.045 and p = 0.03, respectively). 27.5% of all patients had no acute toxicity. Three patients with acute and four patients with late grade 3 toxicities were reported. CONCLUSION: Normofractionated radiotherapy is a feasible option for rGBM with a good toxicity profile. Simultaneously applied systemic therapy was associated with improved outcome. For MGMT promoter-methylated histology, higher radiation doses improved survival.

Stimulation of the globus pallidus internus in the treatment of Parkinson's disease: Long-term results of a monocentric cohort.

BACKGROUND: Pallidal deep brain stimulation (DBS) has shown to be beneficial in patients with advanced levodopa-responsive Parkinson's disease (PD) in several short-term studies. However, reported long-term outcomes of pallidal DBS for PD are limited and contradictory. METHODS: Eighteen consecutive PD patients were treated with unilateral or bilateral stimulation of the internal part of the globus pallidus (GPi). Assessments were carried out before and six months after neurosurgery, and annually thereafter for up to 16 years (mean follow-up time: 6 years). Primary outcomes included motor signs (Unified PD Rating Scale [UPDRS]-III), activities of daily living (ADL, UPDRS-II), and levodopa-induced motor complications (UPDRS-IV). RESULTS: The results show that GPi stimulation improves levodopa-responsive PD motor signs (UPDRS-III), levodopa-induced motor complications (UPDRS-IV), and ADL (UPDRS-II) in advanced PD. Among motor signs, tremor showed the best response to pallidal stimulation. Levodopa-induced motor complications and tremor showed improvements for more than 10 years after neurosurgery. CONCLUSIONS: The overall findings in our cohort demonstrate that pallidal stimulation is effective in reducing parkinsonian motor signs (UPDRS-III), particularly in the 'off'-medication state. Although the beneficial effects on bradykinesia, rigidity and ADL may be limited to 5-6 years, the follow up results indicate that the improvements of levodopa-induced motor complications (UPDRS-IV) and tremor can be sustained for more than 10 years.

Worth a local treatment? - Analysis of modern radiotherapy concepts for oligometastatic prostate cancer.

BACKGROUND: Prostate cancer (PCA) is the most-prevalent non-skin cancer in men worldwide. Nevertheless, the treatment of oligometastatic, especially lymph-node (ln) recurrent, PCA remains elusive. The aim of our study was to provide insights in radiotherapy (RT)-treatment of recurrent PCA exhibiting ln- or osseous (oss)-oligometastases. METHODS: Between April 2012 and April 2017, 27 oligometastatic PCA patients (19 ln and 8 single oss) were treated with RT at our institution. RESULTS: The metastasis-free survival (MFS) was 24.8 m (22.0-36.0 m) and 25.4 m (23.9-28.1 m) for the ln- and oss-subgroup resulting in 1-year MFS of 75.4 and 100% and 2-year MFS of 58.7 and 83.3% for ln- and oss-metastatic patients, respectively. Of notice, none of the recurrences for ln-patients was in the RT-field, constituting a local control of 100%. Within the ln-group, pre-RT median-PSA was 2.6 ng/ml, median post-RT PSA was 0.3 ng/ml, which was significant (p = 0.003). Median biochemical-free survival (bfS) was 12.2 m. PCA that was initially confined to the prostate had a better bfS (p < 0.001) and MFS (p = 0.013). The oss-group had a median PSA of 4.9 ng/ml pre-treatment which dropped to a median value of 0.14 ng/ml (p = 0.004). Toxicities were moderate, with only 1 case of III° toxicity. There were no deaths in the ln-group, thus overall survial was 100% here. CONCLUSION: Our study points out the feasibility of RT as a treatment option in recurrent PCA and demonstrates an excellent local control with a low-toxicity profile.

Dual energy CT myelography after lumbar osteosynthesis.

PURPOSE: The purpose of this study was to evaluate the benefits of CT myelography in the DE technique in patients with lumbar osteosynthesis. MATERIALS AND METHODS: In 30 patients a DE-CT scan of the spine with tube voltages of 80 kV and 140 kV was performed and a virtual monochromatic series of 120 kV was generated after intrathecal contrast injection. The impact of metal artifacts on the spinal canal and the spinal foramina was evaluated. The visualization of nerve roots was compared between a VRT series of the dural sac and conventional myelography. RESULTS: With tube voltages of 140 kV, the artifacts were least pronounced. As no overlay disturbance was present, VRT visualization of the nerve roots was more reliable than conventional myelography. CONCLUSION: In patients after osteosynthesis, CT in the DE technique provides minimal artifact disturbance using a tube voltage of 140 kV. "Virtual myelography" seems to be superior to conventional myelography for the evaluation of nerve roots. This could reduce additional conventional radiography, may shorten the entire examination and radiation time and diminish unnecessary painful movements for the patient.

Use of multimodal electrophysiological monitoring to predict outcome after subarachnoid hemorrhage? A prospective series.

AIM: Electrophysiological monitoring (EM) is still controversial in the prediction of outcome after subarachnoid hemorrhage (SAH). The absence of evoked potentials (EP) is a good predictor for unfavorable, whereas the prediction of favorable outcome may be less useful. Aim of this study was to evaluate, if multimodal EM provides significant information about the patients' outcome or if this method might be dispensable. METHODS: Multimodal EP data were recorded sequentially in 51 SAH-patients. The following data were recorded: World Federation of Neurological Surgeons (WFNS-) grade, Fisher grading score, endovascular versus neurosurgical treatment, aneurysm location and clinical outcome according to the Glasgow Outcome Scale (GOS). Multimodal electrophysiological monitoring included median nerve somatosensory evoked potential (M-SSEP), tibial nerve somatosensory evoked potential (T-SSEP), flash-visual evoked potential (f-VEP), brainstem auditory evoked potential (BAEP) and central conduction time (CCT) of M-SSEP. EP data were recorded sequentially; the first and last studies were evaluated. RESULTS: No correlation was found between initial and last M-SSEP, T-SSEP, BAEP and initial f-VEP and the patients' outcome. An 'unfavorable' outcome was in conjunction with an initial delayed CCT (>6 ms, P=0.03) and the final f-VEP correlated well with the patients' outcome (P=0.03). CONCLUSION: In conclusion, neither T-SSEP, f-VEP, BAEP nor CCT can be used as valid predictor for outcome after SAH. The patient's initial clinical grading still provides the only satisfying predictor, independent of the patient's clinical course.

Brainstem abscess caused by Haemophilus influenza and Peptostreptococcus species.

We present a patient with a solitary brainstem abscess caused by Haemophilus influenza type b (Hib) and Peptostreptococcus species. This is the first report of a Hib brainstem abscess in the English literature. Hib has been mainly associated with respiratory or nasal infections, and a few cases of intracerebral abscesses, but no brainstem abscesses have been described. The literature on solitary brainstem abscesses was reviewed and an overview of the literature between January 1984 and May 2009 is presented.

The awakened intraspinal glass shard.

Penetrating spinal injuries from foreign bodies are an exceedingly rare pathological entity. In this report we present an unusual clinical report of an in-driven shard of glass in the cervical spine that remained without symptoms for many years and became symptomatic possibly because of narrowing of the diameter of the vertebral canal.

Treatment strategies and outcome in patients with non-tuberculous spinal epidural abscess--a review of 46 cases.

OBJECTIVES: Spinal epidural abscess (SEA) is a rare disease and its early detection and appropriate treatment is essential to prevent high morbidity and mortality. There are only few single-institution series who report their experiences with the microsurgical management of SEA and treatment strategies are discussed controversially. Within the last 15 years the authors have treated 46 patients with SEA. This comparatively high number of cases encouraged us to review our experiences with SEA focussing on the clinical presentation, microsurgical management and outcome. METHODS: Clinical charts of 46 cases with a spinal epidural abscess treated between 1990 and 2004 were reviewed. There were 30 men and 16 women, the age ranged between 32 and 86 years (mean: 57 years). The clinical mean follow-up was 8.5 months (range: 2-84). The clinical presentation and severity of neurological deficits were measured by the Frankel grading system on admission and on follow-up visit. RESULTS: The abscess was located in the cervical spine in 8, the thoracic spine in 17 and the lumbar spine in 21 patients. On admission 8 patients were in Frankel grade A, 7 in B, 15 in C, 8 in D and 8 in E. During follow-up 1 patient was in Frankel grade A, 1 in B, 5 in C, 13 in D and 24 in E. 37 patients underwent primary microsurgery with abscess drainage or removal of chronic granulomatous tissue. The clinical symptoms in 4 patients worsened shortly after the operation due to a compression fracture of the vertebral body (n=2) or progress of the abscess (n=2) making re-operation necessary. 9 patients with severe critical illness or without neurological deficits had primarily a CT-guided puncture for assessment of the causative organism. 3 of them needed additional surgical therapy within the hospital stay because of a new neurological deficit. All patients were immobilised and treated with antibiotics for at least 6 weeks. The mortality was 6.5%. As for complications we noted septicaemia (n=5), meningitis (n=1) and a transient malresorptive hydrocephalus (n=1). CONCLUSION: Early diagnosis, microsurgical therapy with appropriate antibiotic therapy and careful observation of patients are the keys to successful management of SEA. The goal of surgical treatment is to isolate the causative organism and to perform a decompression at the site of maximal cord compression in cases of neurological deterioration or severe pain. Instrumentation with primary fixation does not seem to be imperative. In cases of post-operative worsening, a fracture of additionally infected bony elements has to be considered and a stabilisation should be discussed on an individual basis.

Comparison of perfusion harmonic imaging and perfusion mr imaging for the assessment of microvascular characteristics in brain tumors.

PURPOSE: The purpose of this study was to evaluate the potential of perfusion harmonic imaging (pHI) for assessing microvascular characteristics of brain tumors and to compare this ultrasound technique to perfusion MRI (pMRI). MATERIALS AND METHODS: Twenty-five patients with brain tumors underwent transtemporal pHI and fourteen of these patients underwent additional pMRI. Time-intensity curves of two different regions of interest (ROIs; (1) enhancing tumor; (2) healthy brain) were calculated off-line, and the following parameters were compared between the two ROIs and the two methodologies: time-to-peak intensity (TTP [sec]), the ratios of the peak intensities (PI ratio), the ratios of the positive slope gradient (PG ratio) and the ratios of the area under the curve (AUC ratio). p < 0.05 was considered statistically significant. RESULTS: Four of 25 patients were excluded due to bone window insufficiency or unfavorable tumor location. Focal abnormal echogenicity was detected in native B-mode in 86 % of the patients. Contrast agent administration led to remarkable echo enhancement in the tumor in all patients with corresponding time-intensity curves. Both pHI and pMRI showed significant differences with respect to the mean PI, PG and AUC (pHI: p < 0.001 / < 0.001 / < 0.001; pMRI: p < 0.05 / < 0.05 / < 0.001) when comparing tumor to healthy brain. The TTP was not significantly different in tumor and brain tissue. Comparison of pHI and pMRI data did not show any significant differences for three of four parameter ratios between both methodologies. CONCLUSION: PHI provides a new technique for assessing microvascular characteristics of brain tumors reflecting their abnormal perfusion. Overall comparison of this methodology to pMRI demonstrated encouraging results. Further studies should address the clinical potential of pHI especially in view of microvascular response to anti-angiogenic treatment.

Transmuscular trocar technique - minimal access spine surgery for far lateral lumbar disc herniations.

OBJECTIVE: Minimal access spine surgery (MASS) is gaining increasing importance in microsurgery of the lumbar spine. From a current prospective series we present data on MASS for far lateral lumbar disc herniations (LLDH) via a transmuscular trocar technique (T(2)). The surgical procedure and operative results are demonstrated in detail. In contrast to conventional percutaneous endoscopic techniques, T(2) allows one to operate in the typical microsurgical fashion combined with the advantages of a minimal endoscopic approach with three-dimensional visualization of the surgical target using the operating microscope. METHODS: Microsurgery was performed through a 1.6-cm skin incision with an 11.5-mm diameter trocar that is obliquely inserted into the paraspinal muscles pointing at the lateral isthmus of the upper vertebral body. Fifteen patients were evaluated after a median follow-up period of 24 months. Overall outcome according to the modified MacNab criteria, effect of surgery on radicular pain and sensory or motor deficits, duration of surgery, complication rate, and duration of hospital stay were evaluated. RESULTS: Good to excellent clinical outcomes were achieved in 14/15 patients. Radicular pain and motor deficits improved in all patients postoperatively, while sensory deficits recovered in 13/15 patients. The cosmetic results were excellent in all patients. No aggravation of symptoms after surgery was observed in any of the patients. CONCLUSIONS: The T(2) technique represents an auspicious alternative to standard open microsurgery for LLDH, which allows achievement of excellent clinical and cosmetic results, preservation of segmental spine stability, and avoidance of excessive soft tissue trauma.

Transcranial ultrasound perfusion imaging: implementation of a low MI and a high frame rate.

PURPOSE: Conventional transcranial ultrasound perfusion imaging (UPI) depends on bolus injection and is limited to triggered imaging. To improve our set-ups, we compared two imaging modalities with two different frame rates (FR) and mechanical indices (MI), intending to approach conditions more similar to real time imaging in order to increase parameter precision. MATERIALS AND METHODS: Fifteen healthy volunteers were investigated twice with UPI after i. v. administration of 1 ml of SonoVue(R): first, with a high MI (1.6) and a low FR (0.67 Hz)) and second, with a low MI (1.0) and a high FR (5 Hz). Apart from visual analysis, time-intensity curves were calculated from three regions of interest (ROI) and peak intensity (PI), time to PI (TP), and area-under-the-curve (AUC) were compared between the two imaging modalities. RESULTS: Visually, only scarce contrast enhancement was observed in 10/15 probands, and penetration depth was markedly lower at the low MI/high FR setting, while the high MI/low FR setting lead to very intense enhancement in 13/15 individuals. Signal-to-noise-ratio was higher at the low MI/high FR setting. TP was not significantly different between the two set-ups (p > 0.05). PI and AUC were significantly lower at the low MI/high FR setting (p

Rare intramedullary hemorrhage of a brainstem hemangioblastoma.

OBJECT: Hemorrhages caused by hemangioblastomas are very rare and mostly located in the subarachnoid space. Intraparenchymal bleedings due to hemangioblastomas are even less frequent, and these hemorrhages are almost exclusively located in the supratentorial brain, cerebellum and spinal cord. We report the first case of a brainstem hemorrhage due to a hemangioblastoma of the medulla oblongata. CASE REPORT: A 47-year-old woman presented with acute onset of headache, anarthria, inability to swallow, left-sided hemiparesis and hemidysesthesia with varying states of vigilance, finally developing acute respiratory failure. Cranial computed tomography (CT) scanning and magnetic resonance imaging (MRI) revealed a small hemangioblastoma of the posterior medulla oblongata causing intraparenchymal hemorrhage and acute occlusive hydrocephalus due to intraventricular hematoma extension. RESULT: After implantation of an external ventricular catheter to treat acute hydrocephalus, the hemangioblastoma as well as its associated hemorrhage could be removed in toto via a microsurgical posterior median suboccipital approach with minimal foramen magnum enlargement. During the follow-up period of six months postoperatively the patient showed good recovery with only slight residual neurological deficits. CONCLUSION: The most common causes of brainstem hemorrhages are arterial hypertension and cavernous hemangiomas. However, hemangioblastomas should not be ignored as a possible differential diagnosis for intraparenchymal brainstem hemorrhage. While the prognosis in hypertensive brainstem bleedings is mostly disastrous and surgery rarely indicated, an operative therapy should be considered in cases of hemorrhages caused by underlying tumors. Especially in the treatment of hemangioblastoma, the surgical management strategy is crucial for a successful result. Therefore, the authors recommend including the search for hemangioblastomas into the diagnostic workup in patients with brainstem hemorrhages.

Chiari malformation type I with concomitant persistent trigeminal artery -- report of an unusual case and a review of the current literature.

BACKGROUND: Chiari malformation type I is a stenosis of the subarachnoid space at the level of the foramen magnum due to a small posterior fossa and herniation of the cerebellar tonsils. We present here the unusual case of a Chiari malformation in conjunction with a persistent trigeminal artery and hypoplasia of the basilar artery, also known as a Saltzman anomaly. CASE REPORT: A 34-year-old female physician presented with recurrent headaches, bilateral weakness of deltoid muscles and numbness of the fingertips 3 to 5. A cranial MRI revealed a descent of the cerebellar tonsils to the level of C2 and a supracerebellar cyst. During surgery, a decompressive suboccipital craniectomy was performed. The supracerebellar cyst was fenestrated and the cerebellar tonsils were resected bilaterally. Two days after surgery the patient developed cranial nerve dysfunction and a right-sided hemiparesis. Cerebral angiography revealed a Saltzman type 1 anomaly with persistent primitive trigeminal artery and hypoplasia of the basilar artery. DISCUSSION: This is the first report in the literature about the coincidence of both unusual anomalies. The latest literature of both rare anatomy and the unusual clinical course will be discussed.

Endothelin-1 in plasma, cisternal CSF and microdialysate following aneurysmal SAH.

OBJECTIVE: Endothelin-1 (ET-1) is postulated to play an important role in the development of cerebral vasospasm (CVS) following SAH. This study was conducted to investigate the time course of ET-release in three different sources: CSF, plasma and microdialysate. METHODS: In a prospective study ET-1-concentrations were measured in plasma, cisternal CSF and microdialysate in 20 patients with aneurysmal SAH for at least 8 days after hemorrhage. RESULTS: ET-1 concentration in microdialysate was almost four times higher compared to CSF and plasma. (p<0.001) Only in CSF ET-1-release showed a significant increase over time with highest values on day 5 post ictus (p = 0.03). This was parallel to the increase of transcranial Doppler velocities. ET-1 in plasma and microdialysate did not change over time. CONCLUSION: ET-1 may have a different biological function in different biological tissues. Only ET-1 in CSF seemed to be associated with CVS.