Two-photon laser-scanning microscopy for single and repetitive imaging of dorsal and lateral spinal white matter in vivo.

We developed appropriate surgical procedures for single and repetitive multi-photon imaging of spinal cord in vivo. By intravenous anesthesia, artificial ventilation and laminectomy, acute experiments were performed in the dorsal and lateral white matter. By volatile anesthesia and minimal-invasive surgery, chronic repetitive imaging up to 8 months were performed in the dorsal column through the window between two adjacent spines. Transgenic mouse technology enabled simultaneous imaging of labeled axons, astrocytes and microglia. Repetitive imaging showed positional shifts of microglia over time. These techniques serve for investigations of cellular dynamics and cell-cell interactions in intact and pathologically changed spinal tissue.

Retractorless surgery for intracranial aneurysms.

Microsurgical clipping of intracranial aneurysms often requires access to the subarachnoid space deep in the brain. In the past, fixed retractors have been used to maintain the surgical corridor. However, studies have shown that fixed retraction leads to brain injuries. Here we present strategies to replace conventional fixed retractor blades with dynamic retraction so that the brain is no longer under constant pressure. We show that dynamic retraction without fixed retractors, when combined with optimal patient position and neuroprotective anesthetics, can provide the surgeon with adequate visualization of aneurysms and excellent surgical outcomes.

Venous complications following petrosal vein sectioning in surgery of petrous apex meningiomas.

OBJECTIVE: Meningiomas involving the petrous apex regularly show a close relationship with the superior petrosal vein which is sometimes obliterated during surgery due to its proximity to the tumour. However, there is no study available so far focusing on the frequency of postoperative venous congestion related complications following petrosal vein obliteration as well as on pre- and intraoperative findings related to them. METHODS: Fifty-nine patients with meningiomas involving the petrous apex were analyzed concerning the intraoperative preservation or sacrifice of the petrosal vein and postoperative complications related to venous occlusion. RESULTS: When a petrosal vein was occluded, in 9 of 30 cases venous-related complications occurred with a minor venous-congestion phenomenon in seven cases and major complications in two cases. When the petrosal vein complex was preserved, there were no similar complications. CONCLUSION: Preservation of the petrosal venous complex, especially of large caliber veins, should be attempted whenever possible to increase the safety of surgery. In cases of petrosal vein obliteration, effective brainstem decompression following tumour removal is essential to minimizing the risk of cerebellar congestion.

Real-time 3T fMRI data of brain tumour patients for intra-operative localization of primary motor areas.

INTRODUCTION: In patients with tumours in or near the motor cortex reliable intra-operative identification of the precentral gyrus can be difficult due to anatomical dislocation. Maps of functional magnetic resonance imaging (fMRI) based on the blood oxygen level dependent (BOLD) effect are used to localize eloquent functional areas of the brain but require postprocessing for reduction of false positive activations. We set the focus of this study on the evaluation of feasibility and clinical usefulness of using real-time fMRI t-maps without postprocessing for pre-operative planning and intra-operative localization of functional motor areas. METHODS: Real-time fMRI t-maps from a 3-T MRI scanner were co-registered with MRI data. Ten patients were operated under general anaesthesia using 3D neuronavigation with integrated real-time fMRI t-maps. Surgical and functional outcome was compared to results of 12 patients who previously underwent wake surgeries. RESULTS: Good neurological outcome was achieved in all treated patients. Main activation clusters on fMRI real-time maps were easily identified. Co-registered real-time fMRI data without additional postprocessing were useful in planning the surgical approach. However, due to brain shift and large voxel size of BOLD contrast signals on t-maps exact localization of borders between tumours and functional areas was not possible intra-operatively. CONCLUSION: Our method is very simple to use and effective in guiding the neurosurgeon safely through minimally invasive craniotomies to tumours in eloquent areas without setting lesions to functional areas. Furthermore, the neurosurgeon is more independent when tumour location requires acquisition of fMRI data for pre-operative planning and intra-operative navigation.

Surgical planning for retrosigmoid craniotomies improved by 3D computed tomography venography.

OBJECTIVE: It is impossible to precisely anticipate the crooked course of the transverse and sigmoid sinuses and their individual relationship to superficial landmarks such as the asterion during retrosigmoid approaches. This study was designed to evaluate this anatomical relationship with the help of a surgical planning system and to analyze the impact of these in vivo findings on trepanation placement in retrosigmoid craniotomies. METHODS: In a consecutive series of 123 patients with pathologies located in the cerebellopontine angle, 72 patients underwent surgical planning for retrosigmoid craniotomies based on 3D volumetric renderings of computed tomography venography. By opacity modulation of surfaces in 3D images the position of the asterion was assessed in relationship to the transverse-sigmoid sinus transition (TST) and compared to its intraoperative localization. We evaluated the impact of this additional information on trepanation placement. RESULTS: The spatial relationship of the asterion and the underlying TST complex could be identified and recorded in 66 out of 72 cases. In the remaining 6 cases the sutures were ossified and not visible in the 3D CT reconstructions. The asterion was located on top of the TST in 51 cases, above the TST in 4 cases, and below the TST in 11 cases. The location of the trepanation was modified in 27 cases due to the preoperative imaging findings with major and minor modifications in 10 and 17 cases, respectively. CONCLUSION: Volume-rendered images provide reliable 3D visualization of complex and hidden anatomical structures in the posterior fossa and thereby increase the precision in retrosigmoid approaches.

The use of high-frequency electromagnetics in brain tumour surgery.

OBJECTIVE: The first commercially available high-frequency electromagnetic field (EMF) system promises additional functionality for neurosurgical procedures. In a prospective study, we evaluated the optimal use as well as the limitations of this system designed for vaporizing tissue and for coagulation in brain tumour surgery. METHODS: For the microsurgical treatment of 63 consecutive patients with various intracranial tumours, the EMF system was used in addition to the standard neurosurgical instrumentarium. The system was assessed with respect to its compatibility with the operating room environment. Furthermore, attention was given to the particular techniques required to use the system most effectively. The efficiency of the investigated tool was monitored throughout the study. RESULTS: The EMF system functioned properly in all procedures and did not cause any complications. Specific handling techniques and electrode tip configurations could be defined for optimal use of high-frequency electromagnetics for vaporization and coagulation in different intraoperative settings. Thereby, the efficiency of the device could be increased throughout the study while ineffective use decreased from 7 to 2 cases. Although this tool is designed ergonomically and offers high tactile control, it cannot be used submerged in cerebrospinal fluid or under continuous irrigation, which makes it necessary to use it in tandem with suction devices to obtain a clear view on the surgical field. CONCLUSION: Maneuvering with the EMF system was substantially different to both monopolar and bipolar systems, clearly necessitating a learning curve for the surgeon. This device was found to be a valuable complementary tool to standard electrosurgical instruments when applied effectively and with elaborated techniques.

Cavernous malformation of the internal auditory canal.

Cavernous malformations of the internal auditory canal are a rare clinical entity that, however, should be considered in the differential diagnosis of intracanalicular masses. Even though this type of malformation is usually associated with an evident gadolinium enhancement at MR examination, in some patients, like in this case, the signal characteristics may be not sufficiently specific to allow the correct preoperative diagnosis. Nevertheless, the clinical history, in particular, a rapid onset of cranial nerve deficits, lead to the suspicion of a vascular malformation.

Rapid morphological changes in astrocytes are accompanied by redistribution but not by quantitative changes of cytoskeletal proteins.

Astrocytes have the potential to acquire very different morphologies, depending on their regional location in the CNS and on their functional interactions with other cell types. Morphological changes between a flat or a fibroblast-like and a stellate or process-bearing appearance, and vice versa, can occur rapidly, but very little is known as to whether morphological transformations are based on quantitative changes of cytoskeletal proteins in microfilaments, intermediate filaments, and/or microtubules. Using a cell culture of selective type 1 astrocytes, we compared the distribution and protein amounts of a number of cytoskeletal proteins both during primary process growth induced by specific media conditions and after secondary transformations induced by dBcAMP. Our data presented in this report support the idea that astrocytes can undergo dramatic changes in their morphology requiring subcellular redistribution of most cytoskeletal proteins but no quantitative modifications of the amount of the respective proteins. After pharmacological treatment with lysophosphatic acid and genistein we show that astrocytes can acquire intermediate morphologies reminiscent of both fibroblast and stellate-like cells. These experiments demonstrate that the recently described RhoA-mediated signaling cascade between the cell surface and cytoskeletal proteins is only one of several signaling pathways acting on the astrocytic cytoskeleton.