Cerebellomedullary ganglioglioma: CT and MR findings.

We present a case of cerebellomedullary ganglioglioma in a young child with indolent clinical symptoms. CT demonstrated a region of hypodensity with central contrast enhancement in the right cerebellar hemisphere and the inferior peduncle. On MR the lesion was iosintense on T1-weighted images with fairly homogeneous enhancement with gadolinium, and of high signal intensity on T2-weighted images.

Management and outcome of low-grade astrocytomas of the midline in children: a retrospective review.

Low-grade astrocytomas of the midline of the brain can be difficult to manage because of their location. To evaluate treatment and outcome, we performed a retrospective study of children with midline low-grade astrocytomas admitted to The Hospital for Sick Children between 1976 and 1991. Eighty-eight children with biopsy-proven low-grade astrocytomas were identified. Forty-three tumors occurred in the optic pathways or hypothalamus, 13 in the thalamus, 7 in the pineal region, 14 in the midbrain, and 11 in the medulla. Patient follow-up ranged from 6 months to 15 years, with a mean of 4 years, 9 months. Overall outcome was related to the extent of resection, histological type, and location. Partial resections were often associated with involution of the tumor. Response to radiation was variable, and serious sequelae were observed. Thirty-three patients experienced recurrence, often with a good response to subsequent surgery; however, 12 of these patients died. The probability of survival was calculated to be 96% at 1 year, 91% at 5, and 80% at 10 years. Our study suggests that resection should be considered in all patients, both at presentation and recurrence.

Cerebrovascular histopathology after intracarotid infusion of Gelfoam in the rat.

To evaluate the histopathology of Gelfoam on the cerebral vasculature, 42 Sprague-Dawley rats weighing 250 to 300 g received internal carotid artery infusions of 0.3 ml of Gelfoam solution (5 mg/ml) or normal saline (0.9%). The animals were killed at 1 hour, 5 hours, 3 days, 1 week, 2 weeks, and 4 weeks after the infusion. The brains were removed, sectioned, and stained with hematoxylin and eosin. Examination of brain sections revealed Gelfoam emboli lodged primarily in the small leptomeningeal arteries. At 5 hours after infusion, inflammatory cells were noted in the arterial walls with vessel occlusion. Further canalization of vessels was noted at 1 week. At 4 weeks, Gelfoam was not seen in the specimens. This study suggests that Gelfoam acts as an embolic agent in vessels over short periods of time with no residual inflammatory activity postinfusion.

A concerted effort to prevent shunt infection.

In an attempt to reduce the rate of shunt infection a new protocol for shunt surgery was introduced on July 1, 1988 at The Hospital for Sick Children in Toronto. The operations were done at the beginning of the day, operating room personnel were kept to a minimum, no visitors were allowed in the room, a staff neurosurgeon or neurosurgical fellow attended all operations and two doses of perioperative cloxacillin 50 mg/kg were given intravenously. From July 1, 1988 to June 30, 1989 there were 576 shunt procedures on the Neurosurgical Service and 22 (3.8%) of these resulted in a shunt infection. During the preceding year (July 1, 1987 to June 30, 1988) 581 shunt operations were performed, 75 (12.9%) of which resulted in an infection (chi 2 = 29.9, P < 0.001). It appears that the introduction of this protocol for shunt surgery has helped to reduce the risk of shunt infection from 12.9% to 3.8% (a reduction of 70.5%). The rate of infection occurring after shunt revisions was not significantly different from that occurring after new shunt insertions. When the individual factors in the protocol were analyzed, the use of antibiotics and a shorter duration of surgery appeared to be related to a lower shunt infection rate.

Ascorbic acid-enhanced antiproliferative effect of flavonoids on squamous cell carcinoma in vitro.

We examined the effects of flavone and two polyhydroxylated plant flavonoids (quercetin and fisetin), either singly or in combination with ascorbic acid, on the growth of a human squamous cell carcinoma cell line (HTB 43) in vitro. Fisetin and quercetin significantly impaired cell growth in the presence of ascorbic acid. Exposure of cells to ascorbic acid (2 micrograms/ml) and 2 micrograms/ml of either fisetin or quercetin resulted in 61 and 45% inhibition of cell growth, respectively, in 72 h, while treatment with ascorbic acid alone had no effect on cellular proliferation. Flavone and ascorbic acid, either as single agents or in combination, exhibited no significant inhibition at any of the concentrations tested. The enhancement of the antiproliferative effect of the above flavonoids by ascorbic acid may be due to its ability to protect these compounds against oxidative degradation.

Differential inhibition of proliferation of human squamous cell carcinoma, gliosarcoma and embryonic fibroblast-like lung cells in culture by plant flavonoids.

We investigated the antiproliferative effect of two polyhydroxylated (quercetin and taxifolin) and two polymethoxylated (nobiletin and tangeretin) flavonoids against three cell lines in tissue culture. Tangeretin and nobiletin markedly inhibited the proliferation of a squamous cell carcinoma (HTB 43) and a gliosarcoma (9L) cell line at 2-8 micrograms/ml concentrations. Quercetin displayed no effect on 9L cell growth at these concentrations, while at 8 micrograms/ml it inhibited HTB 43 cell growth. Taxifolin slightly inhibited HTB 43 cell growth at 8 micrograms/ml, while moderately inhibiting HTB 43 cell growth at 2-8 micrograms/ml. The proliferation of a human lung fibroblast-like cell line (CCL 135) was relatively insensitive to low concentrations of the above flavonoids.

Use of allopurinol and deferoxamine in cellular protection during ischemia.

During cellular ischemia and death, many changes occur in the cell. These include the build-up of purines and lipid peroxidation. In this study, we evaluated the effectiveness of allopurinol, which blocks purine breakdown, and deferoxamine, which inhibits lipid peroxidation, as cytoprotective agents. Rats were subjected to middle cerebral artery occlusion and were treated with high or low doses of allopurinol or high or low doses of deferoxamine, with normal saline used as a control. Treatments were given 1 hour before, 1 hour after, or 5 hours after occlusion. The outcome was based on neurological status and infarct size. Both infarct size and neurological status were found to be improved in all treatment groups when compared to controls. This study suggests that the use of these agents prevents cellular damage during ischemia.

Coaptation of the anterior rami of C-3 and C-4 to the upper trunk of the brachial plexus for cervical nerve root avulsion.

No surgical procedure has been available to repair cervical nerve root avulsion inside the spinal canal. Results with peripheral neurotization of denervated muscles have been discouraging. The authors have performed bridge-graft coaptation in three patients with C-5 and C-6 nerve root avulsion. The components of the coaptation included the anterior primary rami of C-3 and C-4 as the donor material, the entire upper trunk as the recipient, and the sural nerve graft as the bridge. This procedure resulted in restoration of motor function in the biceps and shoulder-girdle muscles and produced improved sensation. Stimulation of the C-3 and C-4 nerve roots elicited electrical responses in the biceps and deltoid muscles that indicated nerve growth through the graft and the brachial plexus into these muscles. This reconstructive procedure is effective and should stimulate development of new approaches to treatment of cervical nerve root avulsion and proximal brachial plexopathy.

Antiproliferative effects of citrus flavonoids on a human squamous cell carcinoma in vitro.

We examined the effects of four plant flavonoids (quercetin, taxifolin, nobiletin and tangeretin) on the in vitro growth of a human squamous cell carcinoma cell line (HTB43). Cell cultures were treated with each flavonoid (2-8 micrograms/ml) for 3-7 days. Cell viability, as determined by counting cells, correlated well with that obtained from a colorimetric assay for cellular growth utilizing 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide. The polymethoxylated flavonoids, nobiletin and tangeretin, markedly inhibited cell growth at all concentrations tested on days 5 and 7. On day 3, the inhibition observed was 70-72% at 8 micrograms/ml, while on day 5, it ranged from 61-88% at 2-4 micrograms/ml. Quercetin and taxifolin exhibited no significant inhibition at any of the concentrations tested. This difference in activity may be due to the relatively greater membrane uptake of the polymethoxylated flavonoids since methoxylation of the phenolic groups decreases hydrophilicity of the flavonoid.

Neurological injury and patterns of sacral fractures.

To evaluate the morphological and neurological findings in sacral spine injuries, a retrospective study was conducted of all patients admitted to Erie County Medical Center over a 2-year period with the diagnosis of pelvic or sacral injury. Of these 253 patients, 44 were found to have sacral fractures and form the basis of this study. The type of fracture, neurological deficit, treatment, and outcome in these patients were analyzed. The patient population consisted of 25 males and 19 females, with a mean age of 34 years (range 15 to 80 years). The fractures were classified by the degree of involvement of the foramina and central canal. Fractures through the ala sacralis only (Zone I, 25 cases) or involving the foramina but not the central canal (Zone II, seven cases) were less likely to cause nerve injury (24% and 29%, respectively). Fractures involving the central canal (Zone III), both vertical (five cases) and transverse (seven cases), were more likely to cause neurological injury (60% and 57%, respectively). Neurological deficits in Zone I and II injuries were usually unilateral lumbar and sacral radiculopathies. Zone III deficits were usually bilateral and severe; bowel and/or bladder incontinence was present in six of the 12 patients in this group. Deficits generally improved with time; however, operative reduction and internal fixation may have been useful, particularly in patients with unilateral root symptoms. The treatment options are discussed, and previously published series of sacral fractures are reviewed. The authors conclude that the classification of sacral fractures described is useful in predicting the incidence and severity of neurological deficit.

Leukotrienes in experimental spinal cord injury.

Leukotrienes are a group of noncyclized fatty acid eicosanoids which are formed from the breakdown of arachidonic acid. They are potent mediators of inflammation and may contribute to secondary injury in the central nervous system. All mammalian tissue including cerebral cortex is capable of synthesizing these; however, clear documentation of leukotriene formation in the spinal cord is lacking. We subjected 55 rabbits to weight drops of 200, 300, and 400 gm/cm, respectively, on an exposed spinal cord. The traumatized spinal cord was removed after periods of 15, 30, and 45 minutes and 1, 2, 4, 8, and 24 hours. Radioimmunoassay for leukotriene B-4 was then performed on the specimens. Significant (p less than 0.05) elevation was noted in the 200 and 300 gm/cm groups with peak levels occurring in the first 4 hours. The 400 gm/cm group showed significant depression of values below control levels from 2 to 24 hours. We conclude that in sublethal central nervous system injury leukotrienes are produced in significant amounts and may contribute to secondary spinal cord injury.

Rhinocerebral mucormycosis with extension to the posterior fossa: case report.

A 25-year-old man with juvenile onset diabetes presented with rhinoorbital mucormycosis. He was treated aggressively with orbital extirpation and amphotericin B. Six months later, he presented with posterior fossa extension of the mucormycosis.

Traumatic intracerebral hematomas: timing of appearance and indications for operative removal.

Immediate and delayed traumatic intracerebral hematomas (ICH) can produce devastating secondary brain damage after severe head injury. The relationship between the initial injury and eventual occurrence, size, and time of appearance of such hematomas is not well understood, but has great importance since delayed appearance may necessitate delayed surgical decompression of developing lesions not present on early CT scans. We reviewed the records of 35 consecutive patients with operated post-traumatic ICH to document when these lesions appeared on CT, what were the indications for surgery, and what was eventual outcome. Time between injury and ICH appearance was categorized as immediate (0-3 hours), intermediate (3-6), delayed (6-24) or very delayed (later than 24 hours). ICH appearance was immediate in 20%, intermediate in 6%, delayed in 29%, and very delayed in 46%. Half of the patients were not comatose at the time of admission (GCS greater than or equal to 8). Hematoma removal was prompted by clinical deterioration or failure to improve in half the patients and by uncontrolled intracranial hypertension in the other half. Half the patients died, generally those in traumatic coma immediately after injury although advanced age also was associated with poor outcome. Only about one quarter of patients who require surgical removal of ICH can be shown to have their lesions soon after injury. Most operable intraparenchymal clots develop after initial CT scanning and trauma surgeons must be prepared to recognize and treat this delayed complication of brain injury. Even with aggressive management, ICH contribute significantly to poor outcome and improved treatment must be sought.

Acute spontaneous cerebellar hemorrhage.

Acute spontaneous cerebellar hemorrhage presenting with ataxia, dysarthria, vomiting, dizziness, and coma is commonly the result of hypertension. Early diagnosis is possible, and appropriate treatment, if timely executed, may be lifesaving.