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PURPOSE OF THE STUDY: To evaluate the efficacy of fractionated stereotactic reirradiation with CyberKnife (CK) performed in 6 patients with high grade gliomas treated in Luxembourg with local recurrence (LR). PATIENTS AND METHODS: Between 04.2014 and 06.2016, 6 patients with multiform grade IV gliomas LR were reirradiated with CK (protocol CNER re-RT CFB 1), as reirradiation. The mean time between primary radiotherapy and local recurrence (LR) is 14.1 months [4 - 38]. CK is performed with a dose of 36 Gy in 6 fractions (5 cases) and 30 Gy in 3 fractions (1 case) Results : LR after CK (progression free survival) is 3.4 months [2 - 7] (5 cases assessment). Mean survival after CK is 12 months [3 - 22] (3 cases assessment). Mean survival after initial diagnosis is 37 months [17 - 58] (3 cases assessment). No toxicity is noticed (4 cases assessment). Time to first progression after primary treatment is a strong predictor for survival. Fractionated stereotactic reirradiation with CK is well tolerated and effective (survival) in patients with LR high grade gliomas. In accordance with these results, the CFB Conseil Scientifique recommends a new paradigm for MRI follow-up high grade gliomas. After first line treatment, an MRI has to be performed every 3 months, to identify LR earlier, and to offer the patients a way of salvage with CK option, in order to increase his chances of better survival.

[Radioinduced brain cyst: case report]. / Kyste radioinduit du cerveau: case report.

We present a case of intraparenchymal radioinduced cyst of the brain observed in our department. It is a rare and relatively benign pathology which is usually treated conservatively or by surgery. We emphasize long-term imaging follow up in patients treated by radiosurgery, which can lead to the demonstration of multiple adverse events such as tumefactive cyst formation.

NOAC and intracerebral bleeding--presentation of four cases and review of the literature.

AF might be a life threatening disease. Patients have been under oral antithrombotic treatment in order to avoid thrombotic events. Although this treatment proved to be effective in the last decades there was always the inconvenience of a regular blood control. In the last months NOACs have been flooding the market promising to be as effective as their older concurrents in certain circumstances and highlighting the fact that the control of INR has become obsolete. However, as there is no specific antidote up to date, NOACs might present a life threatening event in case of an intracerebral haemorrhage. The brain surgeons might find themselves in a difficult situation when they have to decide whether to operate on a patient with a compromised haemostasis or not. We present four patients who were treated with NOACs for AF. Three of them were admitted with intracerebral haemorrhage in our neurosurgical unit from January to October 2013. The fourth patient bled one week after stopping his treatment with NOAC. Furthermore we take a closer look to the existing literature and try to portray the issue from a neurosurgical point of view.

Posterior fossa mass in immunosuppressed patient.

BACKGROUND: Toxoplasmosis is the most frequent opportunistic infection of the central nervous system among individuals with the acquired immunodeficiency syndrome. Radiographic modalities include brain CT, MRI and PET scan. The differential diagnosis are usually: primary CNS lymphoma, cerebral metastasis, Progressive multifocal leukoencephalopathy, cytomegalovirus. It indicates severe immunodeficiency and, if it remains untreated, it may lead to death. CASE DESCRIPTION: A 65 year old immunodeficiency woman with a Non Hodgkin Lymphoma treated with Chemotherapy. She had been suffering from vomiting, headache and vertigo. Treatment she received Dafalgan, Betaserc, neupogen and nexiam. CONCLUSION: This case illustrates that a brain biopsy is compulsory before starting any treatment.

Vitamin B1 in the treatment of Wernicke's encephalopathy due to hyperemesis after gastroplasty.

Wernicke's encephalopathy (WE) is a severe brain disorder, first described in 1881, and is caused by a nutritional deficiency of thiamine (vitamin B1) found mostly in patients suffering from chronic alcoholism. In addition, WE can also complicate bariatric surgery if adequate vitamin supplementation is not insured. Without immediate treatment, the prognosis is poor and the mortality rate is high. Most patients present with atypical neurological symptoms, which hampers rapid diagnosis. We present a 40-year-old woman who underwent gastroplasty combined with gastric banding for severe obesity. She experienced repetitive vomiting and her diet was without vitamin supplementation. After three months she developed convergent strabismus, apathy and urinary incontinence, which was diagnosed as WE and treated as such. Six months later her recovery was incomplete, still showing gait difficulties and nystagmus. We aim to show that adequate vitamin supplementation in patients undergoing gastroplasty is necessary, especially considering the risk of permanent neurological deficits.

DTI of the visual pathway in cerebral lesions.

Diffusion tensor imaging (DTI) can be used to localise the visual pathway (VP). In the service of the neurosurgery we have been working since the beginning of this year to develop a protocol which is suitable for the every day clinical routine to show the tracts of the white matter. Many lesions of the brain concern the white matter. Up to date it is still difficult to portray the visual pathway. Many centers all around the world are actually trying to localize the visual pathway, yet it is still used for the research. The application of the DTI-data for surgical interventions remains still a rarity. We believe that using this technique it would reduce the intraoperative risk and improve the postoperative outcome. From the beginning of this year we have been able to localize the visual pathway in 14 patients with different illnesses and we performed also postoperative controls. Using this new technique we were able to minimize the intraoperative risk in our patients.

Salmon jumping: behavior, kinematics and optimal conditions, with possible implications for fish passageway design.

Behavioral and kinematic properties and capacities of wild migratory salmonid fishes swimming upstream and jumping up waterfalls generally have played only minor roles in the design and construction of passageways intended to help these fishes get past dams and other human-made obstacles blocking their movements. This paper reports the results of an experimental study of relevant behavioral and kinematic properties of adult kokanee salmon (Oncorhynchus nerka) jumping up waterfalls as they migrate upstream. We used a portable, adjustable apparatus to study in the field fish responding to artificial waterfalls under a range of flow conditions. We observed fish under conditions of varying water flow rates, pool depths, fall heights and fall angles. We analyzed digital video recordings of their behaviors. Kokanee salmon spontaneously jump up waterfalls within a relatively narrow range of conditions, including low flow speeds, near vertical angles and pool depth to fall height ratios near 1.0. Preferred values for each parameter are, to some extent, dependent on other parameters. In contrast to previous misconceptions, jumping behavior is initiated by running S-start accelerations from beneath the boils formed in the plunge pools below waterfalls, as opposed to C-start standing jumps from the surface. S-starts are immediately followed by burst swimming to the point of takeoff at the surface. These results can contribute to an improved basis for developing designs of fish passageways that may ultimately make them more effective and efficient.

The Miethke dual switch valve: experience in 169 adult patients with different kinds of hydrocephalus: an open field study.

OBJECT: In spite of the development of approximately 200 different shunt systems within the last 50 years, overdrainage and valve obstructions are still major problems in the current treatment of hydrocephalus. In 1994, a new gravitational valve with different opening pressures (depending upon the patient's posture) and a big contact area to CSF was introduced by Miethke and co-workers (DSV). We report about a single institution's experience in the treatment of 169 adult patients with different kinds of hydrocephalus with this valve. METHODS: We retrospectively reviewed the clinical and radiological data of all patients who were treated with a DSV between 1998 and 2005 at our institution. A telephone interview was perfomed at the end of the study, to determine the overall shunt survival. We analysed the outcome and the shunt-related complications. RESULTS: Among 169 patients with DSV, we had 70 patients with normal pressure hydrocephalus (NPH), 40 patients with communicating hydrocephalus due to SAH, 31 patients with communicating hydrocephalus not due to SAH and 28 patients with occlusive hydrocephalus. We had a rate of shunt responders of 93.2%, an overdrainage rate of 3.2% and no valve obstruction in the whole series. The overall shunt survival was 81% after 82 months (mean follow-up: 47.6 months). All implantations were performed by the whole staff, as well as by residents of the neurosurgical department. DISCUSSION: Among the currently available shunt systems, this series is one with the lowest complication rates due to overdrainage and valve obstructions. In patients with NPH, where low opening pressures are essential, the DSV seems to bear an advantage because of a high drainage rate and, in spite of this, a low rate of overdrainage. Even in patients with relatively high CSF protein content, we did not observe any valve obstruction. This study was an open field analysis providing data about the current complication rates of hydrocephalus treatment with this shunt system, outside of a specialized hydrocephalus team or a prospective study trial. However, this study is a retrospective analysis and a prospective randomized controlled trial is required for the comparison of these valves with other shunt systems, such as programmable and flow-controlled ones is required for the future.

Hypothalamic deep brain stimulation for cluster headache: experience from a new multicase series.

Deep brain stimulation (DBS) of the posterior hypothalamus was found to be effective in the treatment of drug-resistant chronic cluster headache. We report the results of a multicentre case series of six patients with chronic cluster headache in whom a DBS in the posterior hypothalamus was performed. Electrodes were implanted stereotactically in the ipsilateral posterior hypothalamus according to published coordinates 2 mm lateral, 3 mm posterior and 5 mm inferior referenced to the mid-AC-PC line. Microelectrode recordings at the target revealed single unit activity with a mean discharge rate of 17 Hz (range 13-35 Hz, n = 4). Out of six patients, four showed a profound decrease of their attack frequency and pain intensity on the visual analogue scale during the first 6 months. Of these, one patient was attack free for 6 months under neurostimulation before returning to the baseline which led to abortion of the DBS. Two patients had experienced only a marginal, non-significant decrease within the first weeks under neurostimulation before returning to their former attack frequency. After a mean follow-up of 17 months, three patients are almost completely attack free, whereas three patients can be considered as treatment failures. The stimulation was well tolerated and stimulation-related side-effects were not observed on long term. DBS of the posterior inferior hypothalamus is an effective therapeutic option in a subset of patients. Future controlled multicentre trials will need to confirm this open-label experience and should help to better define predictive factors for non-responders.

Organometals of tin, lead and mercury compounds in landfill gases and leachates from Bavaria, Germany.

Organo-Sn, -Pb and -Hg compounds were monitored in gases and leachates of 11 municipal waste landfills and one hazardous waste landfill from Bavaria, Germany, with the objectives to estimate the methylation of Sn, Pb and Hg and to assess the risk of their release into the adjacent environment. In the gases, tetramethyl Sn predominated (>80% of total gaseous Sn) with concentrations up to 160 microg Sn m(-3). Dimethyl-Hg and tetramethyl-Pb were only occasionally detected with concentrations up to 2.9 and 2.1 microg m(-3) as Hg or Pb, respectively. In all leachates, trimethyl-Sn dominated with a maximum concentration of 2100 ng Sn L(-1). No organo-Pb compounds were found, and monomethyl-Hg was detected in only one leachate. The concentrations of trimethyl-Sn were up to 100-fold higher in the condensate water than in leachates, and the concentrations of organo-Sn compounds were lower in the adjacent groundwater than in the corresponding leachates. The high abundance of methylated Sn species in the gases and leachates indicates Sn methylation, suggesting the landfill as a source for organo-Sn compounds. In comparison, methylation of Hg and Pb was of little importance, probably due to low Hg concentrations and low rates of Pb methylation in the landfill. The risks of organo-Sn compounds release to the adjacent air is low due to flaring of landfill gases. However, there is probable release of organo-Sn compounds, especially trimethyl-Sn, to the adjacent groundwater.

Emissions of organo-metal compounds via the leachate and gas pathway from two differently pre-treated municipal waste materials -- A landfill reactor study.

Due to their broad industrial production and use as PVC-stabilisers, agro-chemicals and anti-fouling agents, organo-metal compounds are widely distributed throughout the terrestrial and marine biogeosphere. Here, we focused on the emission dynamics of various organo-metal compounds (e.g., di,- tri-, tetra-methyl tin, di-methyl mercury, tetra-methyl lead) from two different kinds of pre-treated mass waste, namely mechanically-biologically pre-treated municipal solid waste (MBP MSW) and municipal waste incineration ash (MWIA). In landfill simulation reactors, the emission of the organo-metal compounds via the leachate and gas pathway was observed over a period of 5 months simulating different environmental conditions (anaerobic with underlying soil layer/aerated/anaerobic). Both waste materials differ significantly in their initial amounts of organo-metal compounds and their environmental behaviour with regard to the accumulation and depletion rates within the solid material during incubation. For tri-methyl tin, the highest release rates in leachates were found in the incineration ash treatments, where anaerobic conditions in combination with underlying soil material significantly promoted its formation. Concerning the gas pathway, anaerobic conditions considerably favour the emission of organo-metal compounds (tetra-methyl tin, di-methyl mercury, tetra-methyl lead) in both the MBP material and especially in the incineration ash.

The value of micro-Doppler in stereotactic brain biopsy.

OBJECTIVE: The aim of this study was to analyse the value of intraoperative micro-Doppler in stereotactic brain biopsy (SBB). So far, only a few studies have reported about the usefulness of micro-Doppler in stereotactic brain biopsy. METHODS: Between 1998 and 2003, 155 SBBs were performed in 153 patients with micro-Doppler (81 males, 72 females, mean age: 59 years). All operations were performed using a ZD-frame and a multiplanar computer tomography-guided trajectory planning system (Leibinger SPP). A 16 MHz micro-Doppler probe (diameter 1 mm, DWL) was used in all cases to explore the area of biopsy before the tissue probes were taken. Serial biopsies (mean, 6 samples) were taken with the Sedan side-cutting cannula (n = 145) or the small forceps (n = 10). We evaluated the number of intraoperative detectable vessel signals by micro-Doppler, intraoperative bleedings as well as bleedings detected by postoperative CT (which was performed in all cases). We compared our results according to bleeding-related complications with the data of stereotactic biopsy series from the recent literature. RESULTS: A conclusive histopathological diagnosis was achieved in 150/153 patients (98 %). A re-biopsy had to be undertaken in 2 cases. In 98 biopsies (63 %), no vessel could be detected with the micro-Doppler. In the remainder, a signal of arterial vessels was detected in 22 (14 %) and a signal of venous vessels in 35 cases (23 %). Detection of a vessel in the micro-Doppler led to a change of the biopsy site in each case within the same trajectory. Biopsy-related bleedings were detected in 4 cases (2.6 %). Among these, the only bleeding which occurred without any signs of vessels in the micro-Doppler happened in a case of a melanoma. The overall biopsy-related permanent morbidity was 0.6 % (n = 1). The biopsy-related mortality was 0. CONCLUSIONS: Despite the overall high security of SBB, the use of intraoperative micro-Doppler may lead to an additional reduction of the risk for a biopsy-related bleeding without enormous expense.

Alteration of cerebral perfusion in patients with idiopathic normal pressure hydrocephalus measured by 3D perfusion weighted magnetic resonance imaging.

OBJECTIVE: It is controversial whether alteration of cerebral perfusion plays an important role in the pathophysiology of patients with idiopathic normal pressure hydrocephalus (NPH) and can help to predict the outcome after shunt surgery. MATERIALS AND METHODS: 28 patients with suspected NPH were examined clinically (Homburg Hydrocephalus Scale, walking test, incontinence protocol) and by 3D dynamic susceptibility based perfusion weighted magnetic resonance imaging (PWI-MRI) before and after cerebrospinal fluid release (spinal tap test, STT). The perfusion parameters (negative integral (NI), time of arrival (T0), time to peak (TTP), mean transit time, and the difference TTP-T0 were analysed. RESULTS: Three different groups of patients were identified preoperatively: In group 1 seven patients showed an increase in the cerebral perfusion and a clinical improvement after STT. The second group (9 patients) also revealed an increase of the cerebral perfusion, but no significant alteration of the clinical assessment could be found. In the third group neither the cerebral perfusion nor the clinical assessment changed. 14 of the 16 patients (group 1 and 2) were examined three months after shunt placement. 11 patients showed a good or excellent result, 2 patients revealed a fair assessment, and only 1 patient had transiently improved. No patient was downgraded after shunting. In the patient group 1 and 2 the NI increased significantly (effect size: 34%), whereas in group 3 no significant alteration of NI was observed. CONCLUSION: PWI-MRI improves the prediction of outcome after shunt placement in patients with NPH and can offer new insights into the pathophysiology.

Monostotic lumbar manifestation of fibrous dysplasia--a rare entity.

Monostotic manifestation of fibrous dysplasia in the spine is exceedingly rare. We report the case of a 30 year-old woman suffering from slowly increasing low back pain. Radiologically a polycyclic, slightly gadolinium-enhancing, solitary lesion within the first lumbar vertebral body was detected. The lesion was removed and stabilized with bone marrow transplant. We describe the radiological and histopathological findings.

Paragangliomas of the parasellar region.

Parasellar paragangliomas are rare tumors. As far as we know, only ten cases are described in the literature. Their clinical, pathological, and radiological features and possible origin are discussed in this article and a review of the literature is given. Additionally, we report a new case of a 51-year-old woman with paraganglioma growing in the anterior, middle, and posterior cranial fossa with extended destruction of the skull base. The patient had been suffering from long-standing headaches and facial nerve paresis. Preoperatively, this tumor was suspected to be a meningioma.

Is a combination of Tc-SPECT or perfusion weighted magnetic resonance imaging with spinal tap test helpful in the diagnosis of normal pressure hydrocephalus?

OBJECTIVE: The aim of this study was to evaluate the combination of spinal tap test (STT) with cerebral perfusion measurement assessed either by Tc-bicisate-SPECT (Tc-SPECT) or perfusion weighted MRI (pwMRI), or both, for a better preoperative selection of promising candidates for shunt operations in suspected idiopathic normal pressure hydrocephalus. METHODS: 27 consecutive patients were examined with a standard clinical protocol (assessed by the Homburg Hydrocephalus Scale (HHS)) as well as with 99m Tc-bicisate-SPECT (n=27) or additionally by pwMRI (n=12) before and after STT. The results of these examinations were compared preoperatively for each patient and correlated with postoperative clinical outcome after shunt surgery. RESULTS: Nine patients showed both, a clinical improvement, and increased cerebral perfusion after STT. They underwent shunt surgery with good to excellent results. In another nine patients increasing cerebral perfusion was detected although they did not show a clear clinical improvement after STT. Six of them also received a shunt operation with good to excellent outcome. Three patients of the last group could have an operation. Nine patients did not show any clinical improvement or any kind of increasing cerebral perfusion after STT. Therefore, they did not undergo surgery. The results of SPECT and pwMRI correlated in 92 % of the patients (11 of 12). CONCLUSION: It is concluded that a combination of clinical assessment with SPECT or pwMRI is helpful in the preoperative selection of patients for shunting procedures with suspected NPH syndrome. This combination is a minimal invasive and objective test modality that is superior to STT alone. Further studies are necessary for a comparison of the described imaging techniques with different diagnostic tests in this difficult field of cerebral disease.

Neuromuscular and endocrine control of an avian courtship behavior.

In many species of birds, males perform complex visual and acoustic courtship displays to attract and stimulate females. Some of these displays involve considerable use of the wings and legs, suggesting that they may be controlled by sexually dimorphic spinal motoneurons and their target muscles. Sex steroid hormones are known to organize and activate many sexually dimorphic phenotypes, so these neuromuscular systems may also be steroid sensitive. To test these ideas, we have begun studies of wild golden-collared manakins (Manacus vitellinus) in Central America. Males of this species establish a courtship arena in the forest, where they perform an elaborate dance that includes use of their wings to generate loud snapping sounds. Here we describe male golden-collared manakin courtship behavior, including the various "wingsnaps." We also review our studies, and those of others, showing sexually dimorphic properties of manakin wings, the wing musculature, and sex steroid accumulation in the spinal cord. These data suggest that manakins are useful models for evaluating steroid control of complex peripheral neuromuscular systems.

Adaptations for rapid and forceful contraction in wing muscles of the male golden-collared manakin: sex and species comparisons.

The courtship display of the male golden-collared manakin (Manacus vitellinus) of Panamanian rainforests is noteworthy for several types of whip-crack-like sounds created by a rapid overhead flip of the wings. We have hypothesized that this courtship behavior. which is not performed by females, is associated with steroid-sensitive and sexually dimorphic neuromuscular systems. Presumably, muscles creating the motion of the wingsnap in males are specialized for greater force generation and speed of contraction. We tested this hypothesis by examining mass, fiber diameter, metabolic enzyme activity, and myosin isoform expression in several muscles of male and female manakins and in both sexes of a non-wingsnapping bird, the zebra finch (Taenopygia guttata). We have identified three wing muscles, the scapulohumeralis caudalis, the supracoracoideus, and the pectoralis major, that differ in one or more of these characteristics across sex and species, suggesting they are specialized for faster contraction and greater force production in male manakins. These muscles normally function to raise and lower the wings during flight. As this movement is the principal motion of the wingsnap, these adaptations presumably underlie the performance of the wingsnap display.

[Granulocytic sarcoma (so-called chloroma) as a possible cause of spinal cord compression. Case report and differential diagnosis]. / Granulozytäres Sarkom (sog. Chlorom) als mögliche Ursache einer Rückenmarkskompression. Fallbericht und Differentialdiagnose.

Granulocytic sarcomas (so-called chloromas) are rare extramedullary tumorlike proliferates of myelogenous precursor cells that may de novo precede acute leukemia or coincide with the first manifestation or relapse of acute myeloid leukemia. Rarely, such tumors represent the initial manifestation of a blast crisis in the course of a chronic myeloproliferative disease, such as chronic myeloid leukemia. If they occur in aleukemic patients incorrect diagnoses may result. Differential diagnostic considerations are being discussed by presenting the case of a 58-year-old man who experienced spinal cord compression by an isolated epidural mass lesion.