Self-help activities of brain tumour patients and their relatives.

BACKGROUND: To date, little is known about self-help activities including the acquisition and distribution of information among brain tumour patients and their relatives. The aim of our study was to elucidate patient characteristics, methods of networking and the impact on further treatment. METHODS: A German questionnaire was distributed at nationwide patient meetings and via internet forums. It was returned electronically or by regular mail. RESULTS: Mean age of the 129 patients was 43.2 years. Mean age of the 140 relatives (94% family members) answering the questionnaire was 42.6 years. 51% of the patients and 60% of the relatives had a university degree. 61% of the patients suffered from high-grade tumours, and 80% of the relatives were caring for high-grade tumour patients. The higher the grade of the tumour, the earlier self-help was begun after diagnosis. The majority of the patients (36%) and their relatives (54%) spent between 1-4 h per week on self-help activities. More than 80% used the internet, but more than 85% used print products for the acquisition of information. More than 50% felt that they were not given enough information by their treating physician. Motives for self-help were the acquisition of "independent" information and psychological relief from an exchange with other tumour patients. The vast majority was satisfied with the results obtained, and more than four out of five who responded to the questionnaire exchanged information with other patients. The current therapy was influenced by self-help in more than 50% of cases. CONCLUSION: Physicians treating patients with brain tumours face a subgroup of well-educated people aiming to independently verify and possibly supplement and/or modify their prescribed care. With the steadily increasing use of internet resources, this approach can be expected to expand. Physicians should be prepared to deal appropriately with this subgroup of patients and their relatives to ensure that self-help activities support but do not endanger optimal care.

Retrieval of foreign bodies adjacent to the nervous system: aspects of intra-operative use of ultrasound.

The retention of a foreign body during a surgical procedure or the inadvertent migration of an implant are rare but potentially harmful complications. Especially in the case of the former, the legal situation is unequivocal. Nevertheless, the uncomplicated removal and limitation of the operative trauma may be in the interest of the surgeon. We report and illustrate 2 patients in whom the use of intra-operative ultrasound resulted in the safe and elective removal of an intracranial drill tip in one patient and a contraceptive implant located in the ulnar nerve sheath in the other. The characteristic acoustic shadowing artefact could be demonstrated in both examples. In the first patient, intra-operative magnetic resonance tomography could not be used because of the magnetic artefact, and in the second patient, ultrasound was preferred for reasons of simplicity. Intra-operative ultrasound is an appropriate and easily available tool for detection of small foreign bodies beneath the nervous system. The neurosurgeon should be familiar with the typical characteristics of foreign bodies, which is different from other structures.

Intra-operative diagnosis and image-guided management of an intracerebral haemorrhage occurring during ultrasound-guided biopsy.

Haemorrhagic complications occurring after burr-hole procedures are diagnosed only in symptomatic patients or when postoperative imaging is performed routinely. We report the development of an intracerebral haematoma which occurred during ultrasound-guided burr-hole biopsy. Real-time ultrasound through the same burr-hole enabled us to determine the dynamics of the bleeding and its terminal volume. The operation was finished without further complications and the patient did not experience an impairment of her neurological state. Intra-operative ultrasound is capable of detecting "invisible" complications during burr-hole procedures.

Minimally invasive neurosurgery within a 0.5 tesla intraoperative magnetic resonance scanner using an off-line neuro-navigation system.

BACKGROUND AND PURPOSE: We evaluated an advanced concept for patient-based navigation during minimally invasive neurosurgical procedures. METHODS: An infrared-based, off-line neuro-navigation system (LOCALITE, Bonn, Germany) was applied during operations within a 0.5 T intraoperative MRI scanner (iMRI) (Signa SF, GE Medical Systems, Milwaukee, WI, USA) in addition to the conventional real-time system. The three-dimensional (3D) data set was acquired intraoperatively and up-dated when brain-shift was suspected. Twenty-three patients with subcortical lesions were operated upon with the aim to minimise the operative trauma. RESULTS: Small craniotomies (median diameter 30 mm, mean diameter 27 mm) could be placed exactly. In all cases, the primary goal of the operation (total resection or biopsy) was achieved in a straightforward procedure without permanent morbidity. The navigation system could be easily used without technical problems. In contrast to the real-time navigation mode of the MR system, the higher quality as well as the real-time display of the MR images reconstructed from the 3D reference data provided sufficient visual-manual coordination. CONCLUSION: The system combines the advantages of conventional neuro-navigation with the ability to adapt intraoperatively to the continuously changing anatomy. Thus, small and/or deep lesions can be operated upon in straightforward minimally invasive operations.

Intrinsic brainstem tumours in adults: results of microneurosurgical treatment of 16 consecutive patients.

Intrinsic brainstem tumours in adults have a poor prognosis and surgical resection is rarely performed. Encouraged by successful operations on children performed in our department, we began a more aggressive strategy of open operations. Between 1986 and 1997, we operated upon 16 consecutive patients over 16 years of age (five female, 11 male, mean age 36.9 years) who were suffering from intrinsic tumours located in the pons and/or medulla oblongata. The extent of first open resection was 80 - 100% in two of the cases and more than 50% in nine cases. The mean survival time after the first occurrence of symptoms was 88.1 (median 34.5) months, and 39.9 (median 11) months after the first open operation. The rate of 5-year survival from the first occurrence of symptoms was 37.5% (25% after the first open surgical procedure). Thirteen out of 16 patients died within the follow-up period of at least 6.3 years, two of them within the immediate postoperative period. Eleven patients experienced a postoperative deterioration of symptoms from which only four recovered. Eight patients had from WHO grade II astrocytoma and a similar course as patients with higher-grade gliomas (n = 4). Our results indicate that open microneurosurgery for intrinsic brainstem tumours is of questionable benefit for the patient. Although surgery offers the advantages of reliable confirmation of histopathology and may be associated with prolonged survival, neurological deterioration was common and, unlike in paediatric patients, often irreversible.

Internet-based interaction among brain tumour patients. Analysis of a medical mailing list.

Patients and their care providers are increasingly turning to the internet for information. Being faced with this information of very heterogeneous quality, the physician would do well to be informed about the common internet information sources. We investigated the e-mails of a mailing list (or "support group") serving about 380 brain tumour patients and their care providers. The mails were obtained from an archive and grouped according to their topic. Within 6 months, 3,272 e-mails were distributed to every group member. Alternative treatments were the most frequently discussed topics (15 %). These discussions dealt with serious new strategies as well as dubious drugs and methods. A critical attitude towards "quacks" was common, but not the rule. More than 10 % of the mails dealt with debates about therapeutic strategy and about symptoms. The individual course of the participants' illness was often reported very frankly. Emotional support between members played another great role in the support group. Criticism of physicians was rare compared to recommendations of specific therapists (3 % vs. 4 %) and included lack of empathy or sensibility and poor communication between physicians. The brain tumour mailing list is a communication medium for brain tumour patients and their care providers, which distributes and reproduces information of heterogeneous quality. The physician faced with this information should be unbiased but cautious.

Blood flow velocities in the basal vein after subarachnoid haemorrhage. A prospective study using transcranial duplex sonography.

BACKGROUND: Early recognition of emerging delayed neurological deficits (DND) in patients after subarachnoid haemorrhage (SAH) is not always possible by transcranial Doppler sonography. Aim of this study was to investigate a) whether determination of blood flow velocities in deep cerebral basal veins can predict DND in these patients b) the correlation of venous flow velocity to cerebral blood flow (CBF). METHODS: a) We prospectively investigated the mean flow velocity in the basal vein (VBVR), in the middle cerebral artery (VMCA) and in the extracranial internal carotid artery (VICA) in 66 patients after spontaneous SAH. Examinations were performed daily during the first 10 days, using transcranial duplex sonography. Thirty-seven patients had VMCA exceeding 120 cm/s. They were categorised in three groups: 1: no delayed neurological deficit; II: transient DND; III: permanent DND or death associated with vasospasm. b) In another group of 14 patients, interdiane variations in global cerebral blood flow (CBF) measured by the Kety-Schmidt-method were correlated with variations in VBVR, VMCA, and VICA. FINDINGS: a) In patients without deficit, VBVR was significantly elevated above normal values the first day (p < 0.05), and days 5 and 6 (p < 0.1) after VMCA exceeding 120 cm/s. In group III (permanent deficit), flow velocities in the BVR were significantly below normal on day 5 (p < 0.05) and 9 (p < 0.1). b) The correlation between changes in VBVR to changes in CBF (r = 0.78, p < 0.001) was closer than between changes in VMCA to the changes in CBF (r = 0.54, p < 0.05). INTERPRETATION: In case of elevated VMCA, patients with higher VBVR seem to have a better outcome. Changes in CBF correlate better with VBVR than with arterial flow velocities.

Blood flow velocities in middle cerebral artery branches after subarachnoid hemorrhage.

In a prospective study, 55 patients were examined by transcranial duplex sonography (TCCS) after subarachnoid hemorrhage (SAH) to determine whether additional transcranial duplex examination on the middle cerebral artery M2 segments would aid in the examination of the MCA stem segment. The mean blood flow velocities and pulsatility index were correlated to the occurrence of delayed ischemic neurologic deficits (DIND). Out of 47 patients included, 21 did not experience any delayed deficit (group I), 15 did (group II), and in 11 the extent to which vasospasm contributed to a neurologic deficit was unclear (group III). The highest blood flow velocity and the greatest increase of mean blood flow velocity on 1 day were significantly higher in groups II and III both in M1 and in M2. In 10 patients in group II, where the onset day of DIND was known exactly, Doppler data indicating ischemia before or at the time of DIND were observed in nine. In eight patients, Doppler of the MCA stem alone would have provided enough information to recognize the risk of symptomatic vasospasm; in one patient, only the M2 Doppler gave an indication of ischemic complication. Transcranial duplex sonography may provide additional information to TCD by accurate delineation of M1/M2 vasospasm and therefore may help plan cerebral angiography and neurointerventional treatment.

Rhabdoid tumors of the central nervous system.

Rhabdoid tumors of the central nervous system are rare malignancies with a still almost uniformly fatal outcome. There is still no proven curative therapy available. We report our experience with nine patients with central nervous system rhabdoid tumors. Gross complete surgical removal of the tumor was achieved in six patients. Seven patients received intensive chemotherapy. Four of these were treated in addition with both neuroaxis radiotherapy and a local boost directed to the tumor region, while two patients received local radiotherapy only. The therapy was reasonably well tolerated in most cases. Despite the aggressive therapy, eight of the nine patients died from progressive tumor disease, and one patient died from hemorrhagic brain stem lesions of unknown etiology. The mean survival time was 10 months after diagnosis. Conventional treatment, although aggressive, cannot change the fatal prognosis of central nervous system rhabdoid tumors. As these neoplasms are so rare, a coordinated register would probably be a good idea, offering a means of learning more about the tumor's biology and possible strategies of treatment.

Peroperative cardiovascular stability during brainstem surgery. The use of high-dose methylprednisolone compared to dexamethasone. A retrospective analysis.

BACKGROUND: In neurosurgical procedures within brainstem structures, corticosteroids are routinely administered to prevent oedema and to reduce intraoperative trauma. After replacing the routine administration of dexamethasone (DX) by high-dose methylprednisolone (MP) during surgery for tumours within brainstem structures, a decreased incidence of intraoperative haemodynamic instability events was observed. To test this hypothesis, a retrospective analysis was performed. METHODS: Peroperative data of 62 surgical procedures of brainstem tumours were retrospectively analysed with respect to haemodynamic instability requiring changes in surgical strategy and/or emergence medication with vasoactive drugs. Severe changes in haemodynamic parameters were defined as a significant increase or decrease in heart rate and/or mean arterial blood pressure greater than 30% compared to baseline values. From 1988 to 1994, intravenous dexamethasone was given peroperatively in 33 patients. After a bolus of 1 mg kg(-1) body weight (BW) 30 min preoperatively, 0.2 mg kg(-1) were given every 4 h. From 1994 until now, methylprednisolone was administered instead of dexamethasone in 29 patients. After an initial bolus of 30 mg kg(-1) BW immediately before surgery, 5.4 mg kg(-1) h(-1) were given 23 h postoperatively. RESULTS: The results of this retrospective analysis suggest that the number of operations with episodes of bradycardia, arterial hypotension (P<0.05), tachycardia and arterial hypertension (P<0.005) was significantly decreased in the group of patients treated with high-dose methylprednisolone. CONCLUSION: The retrospective analysis of the clinical data showed that the routine use of high-dose methylprednisolone was associated with a decreased incidence of haemodynamic instability in a selected group of patients undergoing brainstem surgery. This finding has to be proven in prospective double-blind controlled studies.

Expression of nitric oxide synthase isozymes (NOS I-III) by immunohistochemistry and DNA in situ hybridization. Correlation with macrophage presence, vascular endothelial growth factor (VEGF) and oedema volumetric data in 220 glioblastomas.

BACKGROUND: Nitric oxide (NO) is synthesized from arginine by three different isozymes of nitric oxide synthase (NOS I-III). NO has been identified as a powerful metabolite of vascular smooth muscle cell function, cerebral blood circulation and oedema induction. NOS induction by different cytokines has been shown previously in glioblastoma cell cultures and NOS III expression due to astrocytoma grading has been shown in several tumors recently. The aim of the present study was to study the coexpression of NOS I-III, macrophage and capillary presence with VEGF, EGF and their receptors and to investigate a possible mechanism in peritumoral oedema generation. MATERIALS AND METHODS: We have investigated the expression (4-grade values, blinded assay by two observers) of NOS I-III together with those of VEGF, VEGF- R (Flt-1), EGF-R1, von-Willebrand-factor (VWF) and a pan-macrophage marker (Ki-M1P) immunohistochemically in tumor specimens from 220 patients and performed tumor volume morphometry by image analysis in a subgroup of 32 cases to test for any correlation with the peritumoral oedema volumes. Inducible NOS II was further investigated by in situ labelling with a DNA oligonucleotide probe cocktail. RESULTS: All of the specimens revealed some NOS expression, NOS II was expressed in macrophages, microglia and endothelial cells, NOS III and I was localized in glioblastoma cells, NOS III in endothelial cells as well. The highest degrees of expression were observed in 46% (NOS I), 22% (NOS II) and 75% (NOS III) of all specimens. Inducible NOS II in any expression grade was observed in 47.5% of the specimens. Significant correlations were observed for the expression of the macrophage marker Ki-M1P with NOS II (p = 0.024), endothelial NOS III with NOS I (p = 0.0003), VEGF-R1 with NOS II (p = 0.0008) and NOS III (p = 0.011) The oedema volumes could not be correlated significantly with NOS or VEGF-R1 expression values but with those of endothelial staining (p = 0.02). We observed a trend towards higher Ki-M1P expression values together with higher oedema volume extensions. In situ hybridization demonstrated reaction products in endothelial and perivascular regions and sometimes scattered throughout the specimens revealing the labelling of macrophages. CONCLUSIONS: The main source of NO is NOS I and NOS III. The latter is located in endothelial cells and glioblastoma cells. The expression of NOS II in glioblastomas is restricted to infiltrating macrophages. NOS II and III expressions were observed significantly together with that of VEGF-R1. Neither NOS I-III nor VEGF-R expression could be correlated with the extension of the peritumoral oedema.

[Diagnosis and treatment of brain abscesses]. / Diagnose und Behandlung des Hirnabszesses.

The etiologic pathogens of brain abscesses vary depending on the underlying disease. Aerobic and anaerobic bacteria are frequently involved simultaneously. In most cases, the clinical course is subacute. C-reactive protein is the most sensitive inflammatory parameter in the blood. It is elevated in 80 to 90% of all cases. The diagnosis is made by cranial computer tomography without and with contrast enhancement. The rapid culture of pus from the abscess cavity is crucial for the identification of the pathogen. Antibiotic therapy alone is indicated 1. in the presence of multiple, small and/or deep-seated abscesses or 2. when the general condition of the patient does not allow surgery at an acceptable risk or 3. in early cerebritis without capsule formation. Frequently used surgical procedures are abscess aspiration (usually by stereotaxic surgery), open craniotomy and excision of the abscess with the capsule, and open evacuation of the abscess cavity. For empirical treatment the combination of cefotaxime (3 x 2-4 g/d i.v.) plus metronidazol (3-4 x 0.5 g/d i.v.) is preferred. Corticosteroids are indicated in the presence of a space-occupying effect and imminent brain herniation, or of multiple abscesses and abscesses in critical brain regions such as in the cerebellum.

Venous intracranial haemodynamics in children undergoing operative treatment for the repair of craniosynostosis. A prospective study using transcranial colour-coded duplex sonography.

To evaluate intracranial venous haemodynamics in craniosynostosis noninvasively, we measured the blood flow velocities and pulsatility indices in the superior sagittal sinus (SSS) and the middle and the anterior cerebral artery during the perioperative course in 21 children undergoing repair of craniosynostosis involving the midline sutures, using transcranial colour-coded duplex sonography (TCCS). An age-matched group of 12 healthy children was examined in like manner for comparison. In the healthy group, the mean pulsatility index (PI) in the SSS was 0.22 and the mean resistance index (RI) 0.20. The mean preoperative PI and RI in the synostosis group were significantly higher [0.41 and 0.34, respectively (P<0.01)], but fell to 0.19 and 0.17 (P<0.01) in the postoperative course. Our results indicate that in craniosynostosis there is an altered venous haemodynamics in the SSS, which can be observed noninvasively by TCCS.

Visually evoked potentials in 52 children requiring operative repair of craniosynostosis.

We evaluated the prevalence of pathological visually evoked potentials (VEP) before the appearance of papilledema or other signs of elevated intracranial pressure in children suffering from craniosynostosis. In 52 children (19 girls, 33 boys, median age 7.6 months, mean age 7.6 months, range from 3 to 34 months) preoperative VEP were analyzed. In 13 patients, pathological VEP were observed. In all children, both eyes were involved. Only 1 child suffered from papillar anomalies. Latency was pathological in 12 children, whereas the amplitude was suppressed in only 2 children. In all children with preoperative pathological VEP, postoperative controls (n = 4) were improved or normal. Thus, VEP may be the first test for neuronal damage in craniosynostosis.