Pitfalls in surgery of meningeomas of the free tentorial edge.

Clinical experiences from 15 meningeomas located on the free edge of the tentorium are reported. Unexpected findings and complications found in five patients are presented in detail: Despite successful removal without postoperative morbidity after a presigmoid approach the preoperative loss of function of the ophthalmic nerve may cause increasing keratitis, which may result in blindness over the years after surgery. Before a presigmoid approach is performed, angiography or magnetic resonance angiography is advised, because the patient may have only one sigmoid sinus on the tumor side. An acute subdural hematoma as a complication of surgery may not only occur after, but also during surgery with the patient in the semi-sitting position. When a space occupying tumor of the tentorium is discovered, there may be an additional spinal one. If total removal of an extensive tumor of the free edge of the tentorium appears too hazardous, a two-stage strategy with a one year interval may lead to success.

Outcome after mild-to-moderate blunt head injury: effects of focal lesions and diffuse axonal injury.

PRIMARY OBJECTIVE: A comparison of the effects of focal and diffuse axonal injury in mild-to-moderate traumatic brain injury (TBI). RESEARCH DESIGN: In a prospective longitudinal study of 138 consecutive patients suffering from TBI who were admitted to the Magdeburg University Hospital, 60 could be assessed neuropsychologically 8--31 days after trauma and 18--45 weeks later. METHODS AND PROCEDURES: GCS, CT-analysis, comprehensive neuropsychological assessment. MAIN RESULTS: The initial GCS-score was significantly correlated with outcome impairments of semantic fluency and memory in the Wechsler Similarities and in two clinical scales (Neurobehavioural Rating Scale, Frontal Lobe Score). The presence of CT-signs of DAI corresponded with deficits in tasks of response selection and suppression, the presence of focal contusions with results in the clinical scales, reaching significance for behavioural deficits with frontal contusions. Improvements between first and second assessments were pronounced in patients with signs of DAI. CONCLUSIONS: The data indicate that traumatic DAI results in mainly transient neuropsychological deficits. Focal frontal contusions result in more relevant deficits at outcome that affect behaviour and, thus, impair rehabilitation prognosis. It is concluded that even in clinically 'mild' TBI, prognosis and rehabilitation requirements should be established by early imaging and post-acute neuropsychological assessment.

The neuropsychology of blunt head injury in the early postacute stage: effects of focal lesions and diffuse axonal injury.

This investigation evaluated the neuropsychological symptoms in the early posttraumatic period following blunt head injury and their correlation to routine imaging data in a consecutive series of TBI patients (Magdeburg Neurotrauma Databank). Of 135 consecutive patients, 68 could be assessed neuropsychologically 8-21 days after trauma. In 61 patients, routine clinical CT data were sufficient for neuroradiological analysis focusing on the presence or absence of CT signs of diffuse axonal injury (DAI) or focal traumatic injury. In these patients, the initial GCS score was significantly correlated with the presence of DAI but not with focal pathology. The presence of DAI was correlated with behavioral and cognitive symptoms of frontal lobe dysfunction, especially in interference tasks (Go/NoGO and Stroop reaction times) and semantic fluency. The presence of local frontal or temporal traumatic lesions was associated with deficits in concept formation, fluency tasks and behavioral symptoms, but not with increased interference. Patients with frontal contusions were impaired in a task of visuomotor planning and performance (Block design). Our data indicate that both traumatic DAI and focal lesions result in frontal lobe symptoms. We conclude that, even in clinically "mild" TBI, brain imaging should be used to identify patients with substantial brain damage. These should be assessed neuropsychologically for possible posttraumatic cognitive or behavioral impairment. In consideration of its easy accessibility, the refined use of the CT is considered a promising and valid tool for patient stratification. The application of MRI and biochemical markers may further improve prognostic predictions.

Release of biochemical markers of damage to neuronal and glial brain tissue is associated with short and long term neuropsychological outcome after traumatic brain injury.

OBJECTIVES: The present study aimed at the analysis of release patterns of neurobiochemical markers of brain damage (neuron specific enolase (NSE) and protein S-100B) in patients with traumatic brain injury and their predictive value with respect to the short and long term neuropsychological outcome. METHODS: Serial NSE and S-100B concentrations were analysed in blood samples taken at the first, second, and third day after traumatic brain injury. In 69 patients who fulfilled the inclusion criteria (no history of neurological or psychiatric disorder or alcohol or drug dependency, blood sampling according to the scheduled time scale, aged between 16 and 65 years) standardised neurological examinations and qualitative and quantitative evaluation of CT were performed. Comprehensive neuropsychological assessment was performed in 39 subjects 2 weeks after admission and in 29 subjects at a 6 month follow up examination. RESULTS: Most patients presented with minor head injuries (GCS>/=13) at the time of admission. Six months later most patients were fully independent in activities of daily living. Two thirds of the patients, however, still had neuropsychological dysfunction. Patients with short and long term neuropsychological disorders had significantly higher NSE and S-100B serum concentrations and a significantly longer lasting release of both markers. A comparative analysis of the predictive value of clinical, neuroradiological, and biochemical data showed initial S-100B values above 140 ng/l to have the highest predictive power. CONCLUSIONS: The analysis of post-traumatic release patterns of neurobiochemical markers of brain damage might help to identify patients with traumatic brain injury who run a risk of long term neuropsychological dysfunction.

Practicability of intraoperative microvascular Doppler sonography in aneurysm surgery.

Inadvertent narrowing of parent or branching vessels is one major cause of unfavorable outcome from aneurysm surgery. Intraoperative micro-Doppler sonography of arterial brain vessels during surgery for cerebral aneurysms of the anterior circulation was performed in 50 patients and compared retrospectively with 50 patients, who were operated upon without micro-Doppler sonography. Intraoperative micro-Doppler sonography demonstrated the need for repositioning of the clip in 12 instances. Outcome after surgery with micro-Doppler sonography appeared slightly better than without. Micro-Doppler sonography is concluded to be a practicable adjunct to routine aneurysm surgery.

Coping with illness after brain diseases--a comparison between patients with malignant brain tumors, stroke, Parkinson's disease and traumatic brain injury.

PURPOSE: This study investigates coping styles in patients suffering from different brain disorders (malignant brain tumors, stroke, Parkinson's disease and traumatic brain injury). METHOD: In a combined analysis of four prospective studies we investigated 21 patients with malignant glioma at the end radiochemotherapy, 30 patients one year after ischemic stroke, 54 patients suffering from various stages of Parkinson's disease, and 58 patients 6 to 8.5 months after traumatic brain injury. The assessment of coping with illness was based on the Freiburg Questionnaire on Coping with illness. RESULTS: With few exceptions, coping styles did not differ across the various brain pathologies. Differences occurred with respect to 'active, problem-oriented coping' (decreased in stroke patients), and coping by search for religious relief or quest for sense (increased in patients with Parkinson's disease). CONCLUSION: Differences in coping styles could be mainly related to age and social factors. Individual coping strategies seem only to be little related to the type of brain pathology.

Temporal profile of release of neurobiochemical markers of brain damage after traumatic brain injury is associated with intracranial pathology as demonstrated in cranial computerized tomography.

This study aimed at the investigation of release patterns of neuron specific enolase (NSE) and protein S-100B after traumatic brain injury (TBI) and their association with intracranial pathologic changes as demonstrated in computerized tomography (CT). We analyzed NSE and S-100B concentrations in serial venous blood samples taken one to three days after TBI in 66 patients by the use of immunoluminometric assays. These markers are considered to be specific neurobiochemical indicators of damage to glial (S-100B) or neuronal (NSE) brain tissue. Standardized neurological examination and plani- and volumetric evaluation of computerized tomography scans were performed in all patients. Patients with medium severe to severe TBI [Glasgow Coma Scale (GCS) score at the site of accident < or =12] exhibited significantly higher NSE and S-100B concentrations and a significantly longer release compared to patients with minor head injury (GCS: 13-15). Both, patients with and without visible intracerebral pathology in CT scans exhibited elevated concentrations of NSE and S-100B after TBI and a significant decrease in the follow-up blood samples. Release patterns of S-100B and NSE differed in patients with primary cortical contusions, diffuse axonal injury (DAI), and signs of cerebral edema (ICP) without focal mass lesions. All serum concentrations of NSE and S-100B were significantly correlated with the volume of contusions. The data of the present study indicate that the early release patterns of NSE and S-100 may mirror different pathophysiological consequences of traumatic brain injury.

Selective proteolytic cleavage of IL-2 receptor and IL-6 receptor ligand binding chains by neutrophil-derived serine proteases at foci of inflammation.

Traumatic brain injuries induce a strong, locally restricted inflammatory response. Here we demonstrate that activated neutrophils infiltrate the site of tissue destruction and release large amounts of enzymatically active elastase, cathepsin G, and proteinase 3. High intracerebral protease concentrations were found to be accompanied by a reduced inhibitory potential at foci of inflammation. In 39 neurotrauma patients, a temporal correlation between the protease release from neutrophils and the solubilization of interleukin-2 (IL-2) receptor and IL-6 receptor ectodomains at sites of tissue destruction was observed, suggesting that neutrophil-derived proteases may play a crucial role in the cytokine receptor shedding at foci of inflammation. Under in vitro conditions, the cleavage of membrane-bound IL-2Ralpha was found to be predominantly catalyzed by elastase and, to a lesser extent, by proteinase 3. Cathepsin G was found to be incapable of solubilizing this receptor. In contrast, the cleavage of the IL-6R 80 kDa chain was catalyzed by cathepsin G but not by elastase or proteinase 3. The receptor fragments released by the action of these enzymes were found to retain their ligand-binding capacity. These results strongly suggest a pathophysiologic role of neutrophil-derived serine proteases, particularly in regulation of the expression of functional IL-2 and IL-6 receptors at foci of inflammation.

Protein S-100B and neuron specific enolase as early neurobiochemical markers of the severity of traumatic brain injury.

The present study aimed at the predictive value of early release patterns of protein S-100B and neuron specific enolase (NSE) in patients with traumatic brain injury. We investigated 69 patients who were admitted to the Department of Neurosurgery following traumatic brain injury. Both NSE and S-100B serum concentrations during the first three days after admission were highly and significantly correlated with Glasgow Coma and Coma Remission Scale scores at the respective blood sampling times as well as 2 weeks later. Signs of intracranial pathology as evaluated by CCT or MRI scans showed no association with NSE or S-100B release patterns. Our data support the hypothesis that NSE and protein S-100B are useful and sensitive neurobiochemical markers for the early clinical outcome of traumatic brain injury.

Immunohistochemical detection of vascular growth factors in angiomatous and atypical meningiomas, as well as hemangiopericytomas.

The arachnoideal compartment provides the vascular sources for three different tumor types rich in vessels: angiomatous meningioma, some atypical meningioma with high vascularity and meningeal hemangiopericytoma. We investigated immunohistochemically the expression and distribution of vascular mitogenes in 7 angiomatous meningiomas, 8 atypical meningiomas with high vasculature and 4 hemangiopericytomas. On the one hand it should be studied which vascular growth factors such as VPF/VEGF-1, VPF/VEGF-2, bFGF, PDGF and TGF-alpha could be responsible for the close meshwork of vessels within the tumors. On the other hand we were interested in whether or not there are differences in vascular mitogens between slowly growing angiomatous meningiomas and both other types with their increased tendency to recur. PDGF and TGF-alpha were extensively expressed in the endothelium and smooth muscle cells of the vessels, as well as tumor cells. VEGF-2 could only be found in endothelial cells of all three tumor entities. bFGF was localized in some vessels of angiomatous meningiomas and VEGF-1 revealed a very low expression with a localization comparable with VEGF-2. Moreover, uPAR was diffusely expressed in nearly all tumor cells and endothelial cells. The fact that tumor cells of hemangiopericytomas and meningiomas did not show any immunohistochemical reaction with VEGF's could indicate a lower priority of these growth factors for neovascularization in this type of neoplasm. A different expression of vascular mitogens between benign angiomatous meningiomas and atypical meningiomas as well as hemangiopericytomas with their tendency for recurrence could not be observed. The morphological evidence for extravasates of IgG-proteins, Fibrin and Fibronectin due to VPF-effects seems not to be a renouncable condition for neoangiogenesis in the tumors investigated.

Immunohistochemically detectable p53 and mdm-2 oncoprotein expression in astrocytic gliomas and their correlation to cell proliferation.

The aim of this report was to investigate the expression of the p53 and mdm-2 oncoproteins in astrocytic gliomas and to assess their interrelation to proliferating activities. Using monoclonal antibodies directed against p53 and mdm-2, these proteins were stained immunohistochemically in 60 astrocytic brain tumors with different histologic grade. Positive p53 stained nuclei were detected in 25.4% of the tumor cases. Mdm-2 staining products were only localized in 10.5% of specimens. Significant correlations could be found between p53, MIB-1, PCNA and mitotic index on the one hand, and tumor grade on the other hand. There were no clear relations between mdm-2 expression and proliferation markers. The grade of ploidy has a lower priority for the proliferating activity. In most cases mdm-2 immunoreactivity was strongly associated with a low or negative p53 expression.

[Primary leptomeningeal sarcomatosis in a 26-year-old patient]. / Primäre Leptomeninxsarkomatose bei einem 26 Jahre alten Patienten.

Primary malignant mesenchymal tumours were seen in 2.4 per cent of all autopsy cases with primary CNS-tumours. Primary leptomeningeal sarcomatosis is rare in this group of tumours. We discuss the rare disease on the basis of the case history of a 26-year-old patient.

[Cerebral artery aneurysm of the para-ophthalmic artery segment of the internal carotid artery (C4 section)]. / Das Hirnarterienaneurysma am Paraophthalmica-Segment der Arteria carotis interna (C4 Abschnitt).

The number of surgically treated patients with aneurysms included 14 aneurysms located in the Paraophthalmica segment of the A. carotis interna. In six patients only indirect methods (wrapping, establishment of an extra-cranial-intracranial microanastomosis) were used. Clipping of the aneurysmal neck with resection of the aneurysm was reached in six patients. In each case the Processus clinoideus anterior was milled off and the aneurysmal neck was prepared in a sufficient manner for the establishment of the clipping. Intraoperative problems with rupture of the aneurysm and the requirement of definite clipping of the A. carotis interna occurred in two patients. Both patients survived the intervention. One death occurred, it was a young man with a primarily inconspicuous postoperative course and the death was caused by a thrombosis in the carrier vessel.

[Manifestation of sarcoidosis of the optic nerve]. / Die Manifestation der Sarkoidose am N. opticus.

Under the suspicion of an optic nerve glioma a resection of the optic nerve tumour was carried out in a 58-year-old female patient with an amaurosis on the right side. The diagnosis of the sarcoidosis of the Nervus opticus was only established on the basis of the histological findings obtained in the resected optic nerve. Even after a period of observation of five years no further general pathologic signs of the sarcoidosis appeared, so that it could be assumed that this was the case of an isolated sarcoid affection of the optic nerve.

[A completely thrombosed giant aneurysm in an infant]. / Das vollständig thrombosierte Riesenaneurysma im Säuglingsalter.

In a 16-month-old boy completely thrombosed aneurysm in the midline region (Regio pinealis) was successfully extirpated. The clinical symptoms were reduced by a pressure hydrocephalus, which was caused by an occlusion of the passage of the cerebrospinal fluid at the level of the aquaeductus. In the histological picture the inner third of the wall of the aneurysm was imposing as a necrosis with a membrane-like layer of elastin-like proteins on the outward side and adjacent loose connective tissue.

[Meningitis as a complication of anterior-sacral meningocele]. / Meningitis als Komplikation einer anterior-sakralen Meningocele. Ein kasuistischer Beitrag.

A 19-year-old young man was admitted with a serious clinical picture of an infected anterior sacral meningocele. Escherichia coli was identified as the pathogenic organism in the spinal putrid fluid. A catheter percutaneously introduced in the hernial sac served as an external drainage of the fluid. At the same time a systemic antibiotic treatment was carried out. After the sanation, the opening of the meningocele was surgically closed in the interval transdurally from the dorsal direction. For this fibrinous adhesive was used in addition to the suture. After six months the hernial sac closure could be demonstrated in the check-up myelo- and computer tomogram.

[Surgery of aneurysms of the cerebral arteries--results and problems]. / Hirnarterien-Aneurysmachirurgie--Ergebnisse und Probleme.

Surgery has been performed on 100 intracranial aneurysms during the past seven years. Of these, 96 involved the application of microsurgical techniques and could definitely be clipped. Lethality was 8%. Post-surgical deterioration of the clinical neurological status was observed in another 20 patients, but vanished subsequently in 16 of them. Immediate surgery within 48 hours of the subarachnoidal hemorrhage is recommended to avoid subsequent hemorrhage and prevent severe vasospasmic phenomena. Only patients whose general status is good (Hunt and Hess degree 1 or 2) are suitable for immediate surgery.

[Supratentorially located angioblastoma in childhood. Case report]. / Das supratentoriell gelegene Angioblastom im Kindesalter. Kasuistische Mitteilung.

In an 11-year-old girl an angioblastoma in a left parietal position has been successfully removed by a surgical intervention. The process consisted of a highly vascularized tumour part of a firm consistency, which was located in a large cyst. The pre-operatively established computer tomogram showed a hypodensity in the sense of a left parietal cyst and a pronounced environmental oedema. The occurrence of this tumour form in childhood and in the supratentorial section is a rarity.