Evaluation of volumetric changes in differential diagnosis of brain atrophy and active hydrocephalus.

Despite a variety of diagnostic methods, differentiation of symptoms of normal pressure hydrocephalus from those of atrophic processes of the brain is still a difficult task. In the present study an attempt of non-invasive differential diagnosis of normal pressure hydrocephalus (NPH) and brain atrophy (BA) was presented using volumetric analysis of CT images of the head by means of VisNow proprietary software. The analysis was based on the number of voxels converted to the amount of cerebrospinal fluid (CSF) in the subarachnoid space, skull base casters, and the ventricular system. The results demonstrate that the mean volumes of CSF in these compartments in patients with NPH differed significantly from those in BA. Similarly, the mean volumes of CSF in the subarachnoid space and skull base casters in patients with BA differed significantly from those in NPH. Volumetric assessment presented in the paper by application of VisNow software seems useful in the evaluation of NPH and brain BA.

What can be found inside shunt catheters.

Obstruction of shunt catheters is one of the main causes of shunt malfunction. The fragments of shunts removed from five patients were examined using scanning electron microscopy with a (SEM) JEOL JSM-6390 LV microscope. Fifteen catheters from the brain ventricle, lumbar space, and peritoneal space were studied. SEM studies showed that the catheters' surfaces were not sufficiently smooth. The inner surface was often covered by a web of collagen fibrils. Aggregates of red and white blood cells, platelets, lymphocytes, mast cells, and macrophages were trapped in the collagen web. Such cellular aggregates formed a coherent, delicate web mainly consisting of ultrastructurally unchanged cellular elements and were well preserved. Other types of aggregates contained completely destroyed cells that appeared to be submerged in thick collagen web fibrils.We also found a few ultrastructural abnormalities among morphologically unchanged cellular elements. The presence of abnormal red cells showing unusual variability in their shape and size including spherocytosis (thickened, spheroid, and crenate red cells), elliptocytosis (elongated, rod-shaped, or tear-drop red cells), the thalassaemic phenotype of red cells (with inclusion of precipitated unstable hemoglobin in the form of Heinz bodies distorting the red cells, leading to their lysis) was a striking finding. Under scanning electron microscopy, we also recognized swollen or crumpled red cells that looked like potato crisps. Aggregation of thickened blood platelets and white cells was observed frequently. Our study confirmed the importance of the smoothness of the inner surface of the catheter. Smoothness can prevent the formation of cell and protein deposits.

Analysis of postural sway in patients with normal pressure hydrocephalus: effects of shunt implantation.

Poor postural balance is one of the major risk factors for falling in normal pressure hydrocephalus (NPH). Postural instability in the clinic is commonly assessed based upon force platform posturography. In this study we focused on the identification of changes in sway characteristics while standing quiet in patients with NPH before and after shunt implantation. Postural sway area and sway radius were analyzed in a group of 9 patients and 46 controls of both genders. Subject's spontaneous sway was recorded while standing quiet on a force platform for 30-60 s, with eyes open and then closed. Both analyzed sway descriptors identified between-group differences and also an effect of shunt implantation in the NPH group. Sway radius and sway area in patients exhibited very high values compared with those in the control group. Importantly, the effect of eyesight in patients was not observed before shunt implantation and reappeared after the surgical treatment. The study documents that static force platform posturography may be a reliable measure of postural control improvement due to shunt surgery.

Recognition of gait disturbances in patients with normal pressure hydrocephalus using a computer dynography system.

Gait and body balance disturbances are important clinical problems in patients with normal pressure hydrocephalus (NPH). They affect patients' locomotion and lead to a higher risk of falls. The gait pattern may be described as durations of the single and double support and of a stance phase. The aim of the present study was to apply the pattern recognition methods for the evaluation of gait disturbances in patients with NPH before and after neurosurgical treatment (shunt implantation). The results indicate that the parameters measured with a Computer DynoGraphy (CDG) system may effectively differentiate changes of gait in patients with NPH.

Nelson's syndrome -- 46 years later: clinical experience with 37 patients.

OBJECTIVE: Pituitary tumours occurring after bilateral adrenalectomy for Cushing's disease (Nelson's syndrome) are frequently aggressive, so an early diagnosis and careful management are of prime importance. For a new insight into this entity it is necessary to analyse the factors predisposing to its development and the course of the disease, as well as the methods of diagnosis and modalities of treatment. PATIENTS AND METHODS: Thirty-seven patients with Nelson's syndrome were observed, 32 women and 5 men, aged 16 to 61 years at the time of pituitary tumour detection (at present, 27 to 82 years old). The diagnostic methods included clinical observation, imaging examinations (X-ray studies, CT, MRI), hormonal evaluation (especially ACTH and cortisol levels during replacement therapy) and ophthalmologic investigations. Neurosurgery was the main method of treatment. RESULTS: The clinical analysis indicated that young age at the time of adrenalectomy, pregnancy, insufficient replacement therapy and fulminant course of Cushing's disease were the main factors predisposing to Nelson's syndrome. MRI appeared to be the most valuable imaging method, as this detected Nelson's tumours in the microadenoma stage in 7 patients. Plasma ACTH levels varied between 32.6 pmol/l in an early phase to 2 000 pmol/l in the full-blown syndrome. Absolute temporal scotomas found in ophthalmologic examinations were an early abnormality. The best results after therapy were obtained in patients treated by neurosurgery using a transsphenoidal approach in an early stage. CONCLUSIONS: MRI, ophthalmologic examination and plasma ACTH determination were the most valuable investigations for early diagnosis of Nelson's syndrome. Early neurosurgery offered the best outcome in our group of patients.

Mechanisms of vascular dysfunction after subarachnoid hemorrhage.

The main consequence of subarachnoid hemorrhage, for those who survive bleeding, is delayed, persistent vasospasm of intracranial conduit arteries which occurs between the third and seventh day after the insult and results in symptomatic brain ischemia in about 40% of cases. This vasospasm is considered to be a major cause of disability of post-SAH patients. Despite extensive experimental and clinical research, mechanisms of vasospasm are not fully understood. Dysfunction of the endothelium resulting in enhanced production of vasoconstrictors, phenotypic changes of the receptors in endothelium and smooth muscle cells, increased sensitivity of vascular smooth muscle cells to vasoconstrictors, release of spasmogens from lysed blood clot and inflammatory response of the vascular wall have been demonstrated and discussed as pathological mechanisms participating in the development of spasm. In recent years more attention is paid to the functional and structural changes in microcirculation and a concept of microvascular spasm is evolving. Our experimental studies in rat model of SAH strongly suggest that microcirculatory dysfunction and delayed vasospasm are related to the severity of acute, transient ischemia caused by critical decrease of perfusion pressure and active vasoconstriction immediately after the bleeding.

Microscopic stucture of the lamina terminalis: implications for microsurgical third ventriculostomy.

OBJECTIVE: The neurosurgical approach through the lamina terminalis (LT) is a commonly used technique for management of the third ventricle region pathology. Furthermore, LT fenestration is a recommended procedure during surgery of ruptured intracranial aneurysms. Though the LT is a rudimentary structure in adult human brain, its neurosurgical significance is eliciting increasing interest. The aim of the presented study is to characterize the LT histologically, with special attention to the previously recommended area of LT fenestration and to the localization and structure of the organum vasculosum lamina terminalis (OVLT). METHODS: The study was performed on tissue sampled from eight formalin-fixed brains. Paraffin sections taken from various levels of the LT were routinely stained with hematoxylin and eosin (H&E) and by immunohistochemical methods. RESULTS: The LT in the inferior part bordering the optic recess and immediately above the optic chiasm exhibited paucicellular, mainly fibrillar, glial tissue with scanty neural elements and small vessels. At about halfway along the length of the LT an area of loose structure, with an increased number of glial cells, small neurons and thin-walled vessels corresponding to the OVLT was observed. In the majority of examined cases the OVLT was poorly developed and was therefore sometimes overlooked. The superior segment of the LT near the anterior commissure disclosed again paucicellular and slightly loosened fine fibrillar tissue. CONCLUSIONS: The results of the present microscopic study confirm the opinion that the inferior segment of the LT is the most convenient place for safe incision. Its thinnest middle part immediately above the optic recess is composed mainly of gliotic tissue. Above, prominent loosened tissue and the rather rudimental structure of the OVLT seem to be additional favorable factors for a safe fenestration of the LT.

Pure distant, leptomeningeal metastasis of esthesioneuro-epithelioma.

BACKGROUND: Esthesioneuro-epithelioma is a very rare variant of olfactory neuroblastoma that originates in the region of the cribriform plate. Its intracranial manifestation is due to infiltration of the anterior skull base and frontal lobes. METHODS: The authors describe a 52-year-old man with a history of a subtotally resected right maxillary sinus ethesioneuro-epithelioma 2 years earlier who presented with a left hemiparesis and signs of increased intracranial pressure. CT examination revealed a tumour of the right temporoparietal region. The tumour and its dural attachment were totally removed. The patient made a full recovery postoperatively. FINDINGS: The features of esthesioneuro-epithelioma were found on histopathological examination. INTERPRETATION: The intracranial tumour resected was a distant, leptomeningeal metastasis of esthesioneuro-epithelioma. To our knowledge such a documented case has not been published before.

Acute decrease of cerebrocortical microflow and lack of carbon dioxide reactivity following subarachnoid haemorrhage in the rat.

Experiments were designed to study the extent, duration and severity of the impairment of cerebrocortical microciroflow during acute ischemia following experimental SAH in the rat. Twenty five male, adult anesthetized and mechanically ventilated Wistar rats were used. SAH was induced by perforation of the middle cerebral artery (MCA) using intravascular filament. Cerebrocortical microflow (LDF) was recorded bilaterally in the territory supplied by the MCA at normocapnia before SAH and up to 180 min thereafter. Reactivity of microcirculation to CO2 was also studied. In order to further explain mechanisms of post-SAH microcirculatory changes, L-arginine--a precursor of NO and 17-octadecynoic acid (17-ODYA)--an inhibitor of the enzymes of cytochrome P-450 family were administered. SAH resulted in acute decrease of microflow on both sides although during the first 20 min this effect was much better pronounced on the side ipsilateral to ruptured MCA (p < 0.05). Pretreatment with L-arginine or 17-ODYA didn't improve microflow after SAH. On the contrary, in rats pretreated with 17-ODYA LDF on the side ipsilateral to bleeding significantly deteriorated (p < 0.05 vs. control group at all times beginning 10 min after SAH). Following SAH the impairment of CO2 reactivity was also observed.

[Extended translabyrinthine approach in treatment of vestibular schwannomas]. / Poszerzona droga przezblednikowa w leczeniu guzów nerwu przedsionkowo-slimakowego.

Results of removal of vestibular schwannomas using translabyrintine approach were presented. 12 unilateral neuromas were operated. Large neuromas with diameter above 2 cm constituted 75% of all cases. The total resection of tumors was achieved in 10 patients. In all cases anatomical integrity of facial nerve was conserved. In 7 patients facial nerve function was in stage I-III (House Brackmann classification). There were not life threatening complications. Authors underline, that the translabyrintine approach permits to obtain enough wide insight to ponto-cerebellar angle to remove safely, both little and large, vestibular schwannomas.

[Application of the insulating material teflon--pladgets (Genzyme-USA) during the microvascular decompression]. / Zastosowanie materialu izolacyjnego teflon--pladgets firmy Genzyme--USA w operacjach konfliktu naczyniowo-nerwowego nerwu trójdzielnego.

Various isolation materials have been used in the treatment of trigeminal neuralgia due to neuro-vascular conflict. Surgical treatment (MVD) currently utilizes for isolation soft teflon pladgets, which are, after appropriate preparation, placed in the form of wool between the conflicted structures. The material was used in 20 surgical procedures. The definite advantage of this material as compared to others is the possibility to position it correctly between the blood vessel and the nerve without additional fixation with e.g. a tissue adhesive. Observations indicate that this is the best isolation material of those used so far in MVD procedures.

[Qualification of patients with CPA tumors to translabyrinthine approach based on own experiences]. / Wlasne doswiadczenia dotyczace kwalifikacji chorych z guzami kata mostowo-mózdzkowego do operacji z dostepem przezblednikowym.

On the basis of the presented clinical material, the authors present their own observations concerning qualification of the patients with cerebello-pontine angle tumors for surgery utilizing the translabyrinthine approach. The clinical material includes 15 cases of stage II, III and IV cerebello-pontine angle tumors removed through translabyrinthine approach. In view of the fact that there are different opinions concerning the selection of appropriate surgical approach and of a conviction that translabyrinthine approach should be used in case of stage II, relatively small tumors, and that larger, stage III and IV ones should be operated on using the retromastoid approach, we are presenting our views concerning the qualification of patients. In our opinion, the translabyrinthine approach can be used for larger tumors--also for stage IV ones. The translabyrinthine approach was considered only in the cases with total hearing loss and not useful hearing. Of course, in the cases when the tumor penetrates into the middle cranial fossa or into the foramen magnum, the approach may prove rather difficult. As it has been known, the dimensions of the access route are determined by three main anatomical structures: altitude of the bulb of the internal jugular vein, location of the sigmoid sinus and the diameter of the internal auditory meatus. The fundamental advantages of the approach include: no cerebellum retraction required in the case of classic retromastoid approach, easy anatomical and neurophysiological identification of the course of the facial nerve and maintaining its continuity. An approach involving damage of internal ear structures can be performed only if the patient is deaf.

[Indication to translabyrinthine approach to remove of the cerebello-pontine angle tumors--anatomical aspects]. / Wskazania i planowanie dostepu przezblednikowego w operacjach guzów kata mostowo--mózdzkowego przy uwzglednieniu ograniczen anatomicznych.

Indication to translabyrinthine approach to removing of the cerebello-pontine angle tumors--anatomical aspects. Translabyrinthine approach was used in surgical procedures performed for stage II, III and IV tumors of the cerebello-pontine angle of various sizes in 15 cases. In order to ensure a correct course of the procedure and successful removal of the tumor, translabyrinthine approach should be carefully planned on the basis of radiological criteria (CT, NMR). Anatomical limitations of the approach are connected with the localization of the sigmoid sinus, the bulb of the internal jugular vein, pneumatization of the mastoid process and the location of the superior petrosal sinus. In approach planning it should be considered whether the bulb of the internal jugular vein is not located high in relation to the internal auditory meatus, what is the meatus diameter (IAC), location of the sigmoid sinus--its shift to the front is a serious limitation for the approach. The pneumatization state of the mastoid process is also important because of the duration of petrosectomy. Taking into consideration the aforementioned conditions allows to plan precisely and perform the approach appropriate for the tumor size.

[Revascularisation after encephalo-duro-arterio-synangiosis. Case report]. / Rewaskularyzacja mózgowia u chorych po wykonaniu encephalo-duro-arterio-synangiosis. Opis przypadku.

In surgical treatment was performed of patients after cerebral ischaemic stroke and cerebral ischaemia. The authors applied the surgical technique of indirect anastomosis (EDAS-encephalo-duro-arterio synangiosis). The Japanese authors described this method first as a treatment for moya-moya disease. The acetazolamid (Diamox) test and clinical symptoms were the main criteria to perform this surgical procedure. All patient with abnormal Diamox test were treated surgically. After 6 months control angiography was performed to visualize a new network of vessels near the main vessel (superficial temporal artery).

[Embolitic material (coils) dislocation inside a giant and cerebral aneurysm and morphological aneurysm changes after coiling. Case report]. / Przemieszczenie materialu zatorowego (spirali) wprowadzonych do wnetrza olbrzymiego tetniaka oraz zmiany morfologiczne tetniaka. Opis przypadku.

The placement of tungsten coils into aneurysm sack in patient after SAH is a method of treatment used in many neurosurgical departments. The main indications for coiling procedures are severe neurological status (IV i V according to WFNS) and posterior circulation aneurysms. Coiling can be offered to a patient who does not agree to clipping procedure. The presented case is a patient with a giant MCA aneurysm who did not agree to clipping procedure and, therefore, was subjected to coiling. During the follow-up of 2 months; control skull X-rays and after them control angiography were performed to monitor coils arrangement in the aneurysm sack and their possible dislocation. The control angiography after 6 months showed significant enlargement of the aneurysm. The aneurysm was clipped, totally excised and subjected to histopathological examination. It was found that the material inside the aneurysm sack can change its shape due to the impact of the flowing blood (change in the coil shape, resorption and the recanalization of the clot) similarly to the natural process of aneurysm development. Morphological changes of the aneurysm appear to be also possible in spite of the thrombus formation in the aneurysm sack.

[Paranoid syndrome in a patient with tumor in anterior part of corpus callosum. Case report]. / Zespól paranoidalny u chorego z guzem okolicy przedniej czesci spoidla mózgu. Opis przypadku.

The reported case was a patient with tumour situated in the region of the corpus callosum, with symptoms diagnosed initially as affective syndrome and later on as paranoid syndrome. With this diagnosis he was treated for 12 years in psychiatric out-patient clinics and hospitals with antidepressants and and neuroleptics. Brain imaging (CT and MRI) performed only after an epileptic seizure demonstrated a tumour in the anterior part of the corpus callosum with a broad oedema area. Neuropsychological examination revealed disturbances of emotional-motivation processes and defects in cognitive functions. Following surgical treatment only a slight improvement of functioning was noted. Histological diagnosis (PNET) suggested that the tumour was expanding during many years. Much earlier diagnosis with neurosurgical intervention could result in a better therapeutic effect.

Cytoarchitectonic basis for safe entry into the brainstem.

This work is a continuation of the anatomical study in which safe approach zones through the floor of the fourth ventricle--infrafacial and suprafacial--were morphologically and morphometrically defined (Acta Neurochir (1997) 139: 1014-1019). The purpose of cytoarchitectonic study was to analyze correlation between morphometry of the facial colliculus and hypoglossal triangle and localization of the corresponding cranial nerves nuclei in the brainstem tegmentum in order to verify morphometrical borders of the previously defined zones. Morphometrical evaluation of the fourth ventricle floor of 10 examined brainstems was initially performed. Distances from obex to the rostral portion of hypoglossal triangle and facial colliculus were determined. Then a series of axial sections of each specimen, stained for Nissl substance, were analyzed to define the distance from obex to the rostral portion of the hypoglossal and abducens nuclei. Distances of motor trigeminal and facial nuclei from the midline sagittal plane were also measured. The obtained results allowed morphometrical determination of the infra-abducental and supra-abducental region of safe entry into the brainstem tegmentum. Infra-abducental region corresponds to infrafacial safe approach zone and supra-abducental to suprafacial zone. The distance of the rostral portion of facial colliculus from obex was longer than the distance of the rostral pole of abducens nucleus from obex in every examined specimen (by 0.7 mm on average). A very similar correlation between the distance of the rostral margin of hypoglossal triangle and localization of the rostral pole of hypoglossal nucleus was found. The rostral portion of hypoglossal triangle was longer by 1.5 mm on average. The obtained results show that previously defined infrafacial and suprafacial safe approach zones via the fourth ventricle floor correspond morphometrically to tegmental regions of safe entry--infra-abducental and supra-abducental respectively. It suggests that morphometrical evaluation of the fourth ventricle floor proposed by the authors could be useful in the intra-operative determination of safe entry via the rhomboid fossa into the brainstem tegmentum.

Vasostabilizing effect of Dotarizine (Ca(2+)-channel blocker) on cerebrovascular reactivity in rabbits.

Disturbances of the cerebrovascular reactivity in cases of migraine with aura are well-known. It has been suggested that the vasostabilizing effects of novel prophylactic pharmaceuticals are determined by their antiserotoninergic and/or nitric oxide releasing properties. Dotarizine, a representative of Ca2+ channel blockers from diphenilbutilpiperazines group also reveals antiserotoninergic 5-HT2A and 5-HT2C receptor-specific properties. The vasodilatatory and antivasoconstrictive properties of this compound were reported previously. In this study the efficacy of Dotarizine chronic oral administration on cerebrovascular reactivity during hyperventilation was examined with respect to its duration of action. Experiments were carried out on 13 rabbits. There was an interval of two days between a five days compound administration and performed hyperventilation. Blood flow velocities (BFV) in the middle cerebral artery (MCA) and basilar artery (BA) were measured in control conditions, after 10 min hyperventilation and in the tenth minute of recovery of normoventilation. Our data reveal a decrease of antivasoconstrictive properties of Dotarizine between its administration and vasoconstrictive test. Subsequent normoventilation showed a distinct vasostabilising effect of this compound with evident regional differences in its influence on cerebral vessels. Thus Dotarizine might be useful as prophylactic medication in migraine therapy, due to its Ca2+ channel blocking and antiserotoninergic properties, but the time-frame of its efficacy has to be defined.

Regional differences of cerebrovascular reactivity effected by calcium channel blocker - dotarizine.

Dotarizine, a novel antimigraine prophylactic drug, is chemically related to Diphenylbutylpiperazines, which are known to have Ca(2+)-antagonistic, alpha-adrenolytic and antihistaminic properties. Additionally, Dotarizine exhibits strong 5-HT2 receptor-specific antiserotoninergic properties. The vasostabilizing effect of Dotarizine on cerebrovascular reactivity during different ventilation conditions was demonstrated in various in vitro and in vivo studies. In the presented study, the effect of chronic oral administration of the drug on vascular reactions of different areas of cerebral vessels following hyperventilation was investigated. The experiments were carried out on two groups of experimental animals (rabbits). In the first group (6) 25 mg/kg of Dotarizine dissolved in 0.25% agar was administered orally for 5 days twice daily. The control group of animals (6) was fed with agar of the same concentration according to the same time schedule. During the experiment, 15 min hyperventilation was performed and blood flow velocity (BFV) in the middle cerebral artery (MCA) and the basilar artery (BA) was recorded using Transcranial Doppler apparatus (TCD) before and after hyperventilation state. The obtained results revealed a strong antivasoconstrictive effect of Dotarizine on cerebral vessels reactivity during hyperventilation. In the control experimental group, the 15 min hyperventilation caused a decrease in the mean BFV in MCA and BA by 36 and 14%, respectively, and in the drug-treated group under the same ventilation conditions the decrease of the mean BFV in BA was only 6% and even a slight increase (8% as compared with control values) of BFV in MCA was observed. Comparison of the pulsatility index (PI) values demonstrated a significant decrease of vascular resistance in MCA in the Dotarizine-treated group of animals (P<0.1). From the obtained results it can be concluded that chronic oral administration of a novel compound (Dotarizine) diminishes the vasoconstrictive effect of hyperventilation on cerebral vessels in rabbits. The influence of this drug demonstrates regional differences in the cerebrovascular reactivity and it appears to change the vascular resistance in the small arteries of the cerebrovascular system. Thus, it can be recommended as a good prophylactic antimigraine compound due its vasostabilizing properties.

[Assessment of blood flow velocity during cognitive stimulation in persons with suspected hydrocephalus]. / Badanie predkosci przeplywu krwi w czasie stymulacji poznawczej u osób z podejrzeniem wodoglowia.

The aim of this work is to evaluate middle cerebral arteries (MCA) blood flow velocity changes during performance of linguistic and visuospatial cognitive tasks. Two groups were investigated: eight patients with suspected hydrocephalus without perceptible cognitive disturbances, and eight healthy persons. Blood flow velocity in left and right MCA was recorded with transcranial Doppler sonography while the examined patients were performing three different tasks. The analysis of the results showed differences between the groups concerning both increase of blood flow velocity values and performance patterns. Compared to healthy individuals less increase in blood flow velocity during performance of all tasks and no difference in haemodynamic changes between both hemispheres during task performance were observed in patients with hydrocephalus. The results obtained suggest, that the pattern of functional lateralization in brain in patients with suspected hydrocephalus is probably changed.