[Experience with retrogasserian glycerol rhizotomy in the treatment of trigeminal neuralgia.]. / Erfahrungen mit der retroganglionären Glycerin-Rhizotomie in der Behandlung der Trigeminusneuralgie.

From August 1981 to May 1993 a total of 1263 percutaneous retrogasserian glycerol rhizotomies after Hakanson were performed. The intervention was performed with X-ray monitoring under local anaesthesia and rarely lasted longer than 20 min. It achieved good results in the treatment of idiopathic trigeminal neuralgia (TN) and symptomatic trigeminal neuralgia due to multiple sclerosis (TNMS). Some 97% of the TN patients were completely free of pain after the intervention. The recurrence rate within 5 years was 12.8%. Some 94.7% of the TNMS patients were immediately free of pain, but within 2-5 years they experienced a high recurrence rate of 40.2%. The results in the patients with atypical facial pain were more disappointing: only 66.6% were pain-free immediately after the intervention, and the recurrence rate was 31%. With respect to the side effects immediately postoperatively, herpetic eruptions were found in 43.2% of cases. They occurred on the 3rd postoperative day and persisted for 2-3 weeks before being relieved by local virostatic therapy. Hypaesthesia and hypalgesia were present in the early postoperative follow-up in half of our patients. Both these reductions of sensitivity have a tendency to regress. Later, after 2 years, there was reduction in sensitivity of this type in only 20% of cases. In the follow-up 17.5% of our patients complained of dysaesthesia and in 21.4% corneal sensitivity was reduced or lost. We believe that glycerol rhizotomy, owing to its effectiveness, easy applicability, slight distress for the patients and low side effects, should be recommended as a first measure for non-conservative treatment of idiopathic trigeminal neuralgia as well as trigeminal neuralgia in multiple sclerosis.

[Inflammatory paranasal sinus processes and ophthalmoplegia--the expanded diagnostic potentials via computed tomography and magnetic resonance tomography]. / Entzündliche Nasennebenhöhlenprozesse und Ophthalmoplegie--erweiterte diagnostische Möglichkeiten durch Computertomographie und Kernspintomographie.

The ethmoidal sinus often plays a key role in recurring infectious sinusitis. Infections arising from this area are the cause of failure of some conventional and radical operative therapies. The case studies presented here demonstrate that transnasal surgery of the ethmoidal sinus because of an inflammatory process, can cause serious complications. Worsening of the vision with opacity of the paranasal sinuses is not always due to an inflammation. Corresponding disease courses which indicate a connection between eye function disturbances and processes of the paranasal sinuses are presented. A correlation between inflammatory and tumorous diseases of the adjacent paranasal sinuses with ophthalmologic signs can be shown in many patients via computed tomography and magnetic resonance imaging. These methods contribute to the diagnosis of the disease, determination of complications, differential diagnostic evaluation of benign and malignant space-occupying lesions, tumour staging, therapy planning, control of the disease course, early recognition of tumour recurrence and documentation.

Surgical treatment of intramedullary tumors (spinal cord and medulla oblongata). Analysis of 16 cases.

From February 1987 to July 1988, 16 patients of our clinic with intramedullary tumors (seven astrocytomas, six ependymomas, two angiomas with intramedullary hematomyelia, and one angioblastoma of the medulla oblongata) underwent surgery. Radical excision was possible in six cases with tumors in the cervical and/or thoracic region as well as in two cases with tumors in the medulla oblongata. In the group of patients with cervical and/or thoracic tumors, seven showed improvement, up to complete remission of the neurological symptoms. From eight patients with tumors of the medulla oblongata, one patient showed an invasive tumor of the medulla oblongata and pons with corresponding extensive neurological deficits, and died six weeks after surgery. The neurologic symptoms of the other seven patients improved after a postoperative interval of at least six weeks. The surgical approach to tumors of the medulla oblongata or spinal cord was performed by midline incision. Occasionally, a dorsal root entry zone (DREZ) incision was used when the tumor showed strictly unilateral localization. Tumors of the rhomboid fossa were approached by a lateral incision to avoid damage to nuclear structures. The more rostral the tumor localization (medulla oblongata, pons), the less complete was the surgery: only one ependymoma of the medulla oblongata was accessible to total extirpation. The tumor dignity worsened with ascending level of tumor localization. As described generally in the literature, neurological deficits of those patients with tumors in the medulla oblongata increased in the first few postoperative weeks before they began to improve. Chemotherapy, radiation therapy or decompressive laminectomy by themselves only lead to an improvement and are, therefore, not recommended.

Intracerebral subependymomas. Clinical and neuropathological analyses with special reference to the possible existence of a less benign variant.

The frequency of asymptomatic subependymomas was 0.4% in 1,000 serial routine necropsies and 0.7% in symptomatic subependymomas from 1,000 serial surgical specimens of intracranial neoplasms. Among patients with subependymoma (7 symptomatic and 4 asymptomatic), we found 3 cases of marked nuclear polymorphism (NP) in biopsy specimens. The subjective NP was objectively quantified by computer-assisted morphometry, by which a significant difference in nuclear size between these three cases and other cases (p less than 0.005) was revealed. This morphological characteristic correlated with the results of DNA-analysis by flow fluorescence cytometry (FFCM): subependymomas with NP demonstrated higher S and G2/M phases in a diploid pattern than other benign gliomas of our series. From the clinical data including prognosis, however, no remarkable difference was found between the NP group and other groups. The possible existence of less benign variant should be considered in the diagnosis and treatment of subependymoma.

Flow cytometric analysis of cellular DNA content in human astrocytomas and oligodendrogliomas.

This report presents a flow-cytometric analysis of cellular DNA in biopsies and primary cell cultures of 21 human astrocytomas and 19 oligodendrogliomas. A distinct correlation between histological dedifferentiation and pathological DNA distribution was found. Classification was made according to increasing histological anaplasia, corresponding to a four-grade scale and proliferation index (PI). Four types of gliomas were defined according to characteristic DNA patterns and proliferative activities in comparison to their histological grading: 1. purely diploid DNA patterns with low 4C (premitotic) peaks and PI values up to 10 in well-differentiated gliomas; 2. increase of tetraploid cells and PI of 10-16 in tumors with histological grades II or II-III; 3. diploid-tetraploid DNA distribution with PI values up to 30-31 and malignancy grade III; 4. polyploid and aneuploid karyograms with excessive 4C increase, emerging in grade III and especially grade III-IV of these gliomas. Varying DNA distribution during tumor development could be observed in a malignant transformation of an oligodendroglioma I to a glioblastoma after a course of 3 1/2 years. A more detailed subdivision of these tumors according to their DNA content and proliferative activity was achieved. With the exception of occasional variation in karyograms, DNA distribution usually remained stable in primary tissue cultures (PTC).

Impulse cytophotometric DNA analysis in pituitary adenomas.

Flow cytometric DNA analysis was carried out on 32 microsurgically removed pituitary adenomas. Additionally, the histograms of tumor cell nuclei of 7 patients were compared with those of the cultured cells from the same tumor samples. The tumors were classified into 3 groups according to the proliferation index (PI) of the flow cytometric results: 1) tumors with DNA patterns of slow proliferation (PI under 10), to which the majority of the examined pituitary adenomas belonged; 2) pituitary adenomas with diploid karyograms and PI values from 10 to 15; 3) diploid or aneuploid karyograms with PI values above 15. The third group were characterized histologically by increased chromatin content, nuclear polymorphism, mitoses, and extrapituitary infiltration of the tumor cells, and were, therefore, no longer benign. However, there was no direct relationship between the intensity of hormone secretory activity of the tumors and DNA ploidy. Cultured adenoma cells examined by flow cytometry remained stable in all cases but one.

DNA-fluorescence-cytometry and prognosis (grading) of meningiomas--a study of 104 surgically removed tumors.

A total of 104 meningiomas of various histological types were examined microscopically and with flow fluorescence cytometry using the EBR staining technique and either an ICP 11 or an ICP 22 (PHYWE). Also tissue culture cells of 72 tumors were studied for their DNA content. There was a variable DNA distribution, which allowed a grading of malignancy according to a 3 or 4 grade scale. Useful information on the nature of a meningioma and its proliferative activity can be obtained during the surgical treatment. A majority of meningiomas show slowly proliferative DNA patterns typical for benign tumors. More than one third of the meningiomas show an intermediate configuration, probably associated with more or less semi-benign proliferative activity. 5.8% of our cases showed primary malignant tumors--except meningosarcomas.

Symptomatic subependymoma with nuclear polymorphism.

Two patients with symptomatic subependymomas are described. Histologically prominent cellular polymorphism was revealed. The existence of subependymoma with unusually marked polymorphism of the tumor cells should be taken into consideration in diagnosis and treatment.

DNA and prognosis of meningiomas: a comparative cytological and fluorescence-cytophotometrical study of 71 tumours.

DNA analysis in meningiomas was performed using flow-fluorescence cytometry in 71 tumours. Three subcategories of rather small, medium-sized or clearly abnormal growth activities were evident in each of the fibroblastic, transitional and syncytial tumour types. These categories reflected grades 1, 2 or 3 of malignancy on a four-grade scale in which the primary fibroscarcomas of the meninges are grade 4. Richly vascularized (haemangioblastic) meningiomas of our series comprised only two subcategories: these included 7 tumours with slight signs of proliferation and 1 with increased growth, probably indicating a propensity to recur. Tumours of grades 2 and 3 have a tendency to recur, which is probably due more to their biological behaviour than to the efficiency of the surgical treatment. The most variable patterns of DNA distribution are detected in the so-called "anaplastic" meningiomas: some of them are microscopically polymorphous blastomas but show unimodal diploid karyograms, whereas the proliferative indizes, ranging between 1 to 15, were obviously indicative for slow-growing benign tumours. The majority of polymorphous and anaplastic meningiomas, however, are characterized by a rather abnormal tetraploidy or aneu/polyploidy not uncommon in a relapse. The corresponding DNA distribution was demonstrated in a recurrent papillomatous meningioma in agreement with its dubious histological prognosis.

Flow-cytophotometry of nuclear DNA in biopsies of 45 human gliomas and after primary culture in vitro.

DNA distribution in biopsies and cell cultures of human gliomas was examined by flow-fluorescence-cytometry using ethidium bromide staining. Glioblastomas (n = 25) showed "polyploid", "marked tetraploid", or "hypertetraploid" aneuploid karyograms, comparable to subtypes previously proposed by Japanese authors. "Diploid-hyperdiploid" DNA patterns were manifest in 3 cases plus 1 sarcoma--glioblastoma, containing abundant rapidly growing mesenchymal cells. Most tumors showed S-phase increment. "Near-diploid" patterns could be a result of aggregated cells, and small 4 C peaks could be due to non-representative specimens (3 cases). During cultivation, the DNA distribution usually remained stable, but maxima occasionally shifted. Oligodendrogliomas (n = 11) and astrocytomas (n = 9) of low-grade showed low 4 c peaks. High-grade gliomas, however, showed abnormal DNA patterns. Thus, one case of an oligodendroglioma--I developed an abnormal "marked tetraploid" glioblastoma after a 3-year interval presenting its malignant transformation. DNA distribution can obviously vary during tumor evolution. However, it may well support the assessment of grading and more closely define the prognosis in gliomas.

DNA-flow fluorescence--cytometry of ependymomas. Report on ten surgically removed tumours.

The distribution of DNA is estimated from flow cytometric histograms in surgical specimens of ten ependymomas of different location and varying anaplasia. In three cerebral tumours grade I--II, including one ependymoma of the 4th ventricle, only limited elevation of the 4 C maxima was a prominent feature, corresponding to the microscopical frequency of typical mitoses. Four grade-III ependymomas showed aneuploid or polyploid histograms with stem lines. One frontal tumour was classified as "transitional" because of more numerous mitoses and abnormally elevated S and G2 + M phases, which increased in tissue culture. A correlation between the degree of anaplasia with the DNA pattern was difficult to pursue in two spinal ependymomas obviously lacking microscopical mitoses: Both--one a so-called tanycytic variant of grade I--II, and the other probably a metastasis from a cerebellar tumour--had a clear polyploid DNA histogram with a strikingly increased proliferation index, similar to the more malignant tumours of grade III. Also flow DNA measurements probably allow the decoding of heterogenous mixtures of tumour cells which are not always benign in ependymomas of lower grades of anaplasia microscopically.

Flow fluorescence cytometry of deoxyribonucleic acid in meningiomas: studies on surgically removed tumor specimens compared with their cells in primary tissue cultures.

Flow cytometric deoxyribonucleic acid analysis was carried out in 15 meningiomas obtained surgically: two were fibroblastic; one was transitional; four were syncytial with few or no mitoses; three were angioblastic; three were syncytial containing many mitoses and focal micronecroses; one was polymorphic; and one was the papillary type. The histograms of nuclei in the surgical specimens were compared with those obtained from primary tissue culture cells prepared from tumor samples. Five diploid meningiomas had abnormal values for their 4C peaks that were also manifested by their tissue culture cells showing either slightly decreased or increased values during a 7- to 14-day period. Strong variations of the histograms were seen in the original material and in the primary tissue culture of the polymorphic tumor and the aneuploid meningioma of the papilary type. It is suspicious that in vitro proliferating meningioma tissue may be an index for a high risk of recurrence. The results of these seven cases are in contrast to eight further meningiomas of this series with more or less "indifferent" diploid histograms, thus suggesting that there could also be a scale of proliferative potentials of the different meningiomas rapidly demonstrable by means of flow fluorescence cytometry.

[Pneumatocephalus: a clinical contribution (author's transl)]. / Ein Beitrag zur Problematik des Pneumatozephalus.

Treatment of traumatic brain oedema leads to a decrease in raised intracranial pressure, and this may facilitate formation or progression of pneumatocephalus. Lumbar puncture or lumbar CSF drainage for treatment of CSF-rhinorrhoea/otorrhoea is occasionally responsible for the occurrence or enhancement of pneumatocephalus. Pneumatocephalus with radiological absence of fracture of the skull and absence of CSF leakage signifies communication between rhinocranium and encephalocranium: this supplies evidence of an open head injury. Post-traumatic opacification of the sphenoid sinus and presence of suprasellar air, as well as traumatic lesion of the optic chiasma are pathognomonic for the presence of a fracture of the planum sphenoidale. Computerised axial tomography is superior to plain skull x-rays in the localisation of intracerebral air.

[The ENT specialist's responsibility in the diagnosis of the olfactory meningeoma (author's transl)]. / Die Verantwortung des HNO-Arztes bei der Erkennung des Olfaktoriusmeningeoms.

The principal symptoms associate with olfactory groove meningeomas are anosmia and headache which lead the patient to an ENT specialist. Frontal sinusitis, migraine and neuralgia are the most frequent incorrect diagnosis. Positive radiological changes are found frequently on the plain films of patients with these olfactory tumors, even up to 70% according to the literature. It is important to bear this in mind regarding olfactory groove meningeomas to avoid mistakes in diagnosis.

[Microsurgical blood vessel sutures using the so-called fibrin adhesive]. / Mikrochirurgische Gefässnähte unter Verwendung des sogenannten Fibrinklebers.

Since the development of microvascular surgery by Jacobson and Suarez, adaptation of vessel ends of less than 1 mm diameter has been performed by means of 8-10 interrupted sutures. Even the finest suture material, however, produces a foreign body reaction. In addition, necrosis of the media can be seen after insertion of interrupted sutures. After the initial demonstration in 1940 that divided nerves could be successfully rejoined by means of factors from the blood coagulation system, this technique was introduced to microsurgery in 1977. The present investigation was carried out on 50 end-to-end anastomoses in rat common carotid arteries. Subsequently, the healing process was studied by light and electron microscopy. The adhesive used was fibrinogen cryoprecipitate (Fibrinkleber-Human-Immuno), which polymerises after simultaneous application of thrombin. Electron microscopy shows no basic difference between the healing after this technique and the healing process after trauma to the vessel wall. This method, however, prevents regional necrosis of the vessel wall and reduces intimal thickening. The condition of the intimal lining appears better than in sutured anastomoses. The question, whether this change is due only to the absence of sutures or due also to application of fibrinogen, cannot be answered, however.

Intracerebral chondroma.

Intracerebral chondroma is an extremely rare condition. A case of a parasagittal intracerebral chondroma with no meningeal attachment is reported. The clinical and histological findings are described and a review of the literature is presented.

Significance of intravascular and intracardiac movement of the cardiac catheter in ventriculo-atrial shunts (review of 655 cases).

Proper placement of ventriculo-atrial shunts can be complicated by three phenomena: 1. Movement of the cardiac catheter intravascularly into the internal jugular vein as noted on chest X-ray. 2. Movement of the cardiac catheter during intraoperative X-ray leading to blurring and hence problems in accurate localization. 3. No sign on X-ray of the catheter tip or even of the catheter itself despite previous X-ray visualization and good function, a problem to be obviated by better radiopaque markings.