Ultrasound-guided puncture of a Dandy-Walker cyst via the lateral and III ventricles.

Since the Dandy-Walker syndrome was first described by Dandy and Blackfan, Taggart and Walker, the many variants of posterior fossa anomalies, the appropriate management of these malformations and the clinical outcome have been the subjects of controversy. Surgery of the posterior fossa with membrane excision was initially the preferred method of treatment. Unfortunately, there was a high rate of complications, and many of the patients treated in this way still needed a shunting system. Ventricular-peritoneal and/or cysto-peritoneal shunting is commonly used to treat symptomatic posterior fossa cysts of Dandy-Walker malformations and hydrocephalus. Cysto-peritoneal shunt implantation only was associated with a high rate of complications, and most patients so treated needed a ventriculo-peritoneal shunt in addition. According to the literature, combined ventriculo-peritoneal and cysto-peritoneal shunting is needed for satisfactory decompression of Dandy-Walker cyst and hydrocephalus in between 16% and 92% of cases. We report on a young patient with a Dandy-Walker malformation who needed drainage of the posterior fossa and a ventricular shunt. We decided to drain the cyst and the supratentorial ventricles via a single, especially prepared, catheter with many perforations. The catheter was inserted under ultrasound guidance. The tube was inserted from the left lateral ventricle through the foramen of Monro into the III ventricle and downwards into the cyst. Intraoperatively, an immediate decrease in the size of the cyst and the supratentorial ventricles was observed. Postoperative MRI confirmed the exact position of the catheter and sufficient drainage of the posterior fossa cyst and the ventricles. Six months later the girl was seen in our outpatient department. Clinical examination showed no neurological deficit, and MRI demonstrated sufficient drainage of the ventricles and the Dandy-Walker malformation, and in addition hypoplasia of the corpus callosum.

[The value of destructive surgery of the trigeminal nerve in atypical facial pain]. / Zur Wertigkeit destruktiver Eingriffe am Trigeminus bei atypischen Gesichtsschmerzen.

Interruption of trigeminal pathways still is a common treatment in trigeminal neuralgia and has also been suggested for atypical facial pain. The published results in the latter group are rather poor since only 17 to 24% of these patients were free from pain after surgery. There is no information on the outcome of those patients classified as "poor results". We had the opportunity of seeing 48 patients who had been treated without success elsewhere. Pain occurred in most cases after ETN or dental operations. 36 patients underwent, despite poor results after a first neurosurgical intervention, further (up to five) operations. In 58% a postoperative deterioration occurred mainly consisting of anaesthesia dolorosa. Suicidal attempts were four times more frequent than in the group of those patients who had merely not benefited from surgery. In conclusion, the poor results of trigeminal surgery reported in literature and the considerably high risk of postoperative deterioration, as shown in our series, prompt us to warn against destructive trigeminal surgery in atypical facial pain.

[Pseudotumor forms of spontaneous intracerebral hematomas]. / Pseudotumoröse Formen spontaner intrazerebraler Hämatome.

Pseudotumorous types of spontaneous intracerebral haematomas are known from clinical or radiological publications. To our knowledge no study has been conducted dealing with both aspects. A series of 13 cases of spontaneous intracerebral haematomas operated upon as tumours, is reported. In 11 cases the association of atypical clinical course and atypical CT led to the diagnostic error. In 2 cases atypical CTs were erroneous despite a typical clinical course. The atypical clinical features were a progressive course or seizures. The atypical CT findings concerned prolonged hyperdensities, contrast enhancement, ring-shaped and hypodense areas. After discussion of these various findings the authors conclude that a tumour can never be excluded definitely in such cases, and advocate definitive clearing of diagnosis by operation or stereotactic biopsy.

Pharmacokinetics and CSF penetration of moxalactam in antibiotic prophylaxis in neurosurgery.

Moxalactam, a new oxa-beta-lactam antibiotic, suggests a possible role in prophylaxis in neurosurgery. Therefore, CSF penetration of Moxalactam was determined in 12 patients with absence of clinical or laboratory evidence of meningitis. In the dose employed (25 mg/kg 3 times/day) CSF samples showed a penetration of Moxalactam through the blood-cerebrospinal barrier with concentrations higher than 0.1 microgram/ml which persisted for more than seven hours. The drug was well tolerated and adverse effects were not observed.

Neurosurgical treatment of cancer pain.

Neurosurgical pain operations in carcinoma patients should always be considered when conservative treatment methods fail or pain relief can be attained only at the cost of undesired side effects. The therapeutic spectrum of neurosurgery has been appreciably extended in recent years. Due to the introduction of percutaneous surgery methods, the operations have become less burdensome, so that carcinoma patients who were formerly regarded as inoperable can also be given neurosurgical pain treatment. The advances in neurophysiology have led to a better understanding of pain mechanisms, in consequence of which the various possibilities of treatment can be employed more specifically with prospects of better treatment results. The spectrum of neurosurgical treatment extends from destructive measures (rhizotomies, cordotomies, thalamotomies, neurolytics) via intrathecal administration of morphine-like substances to the augmentative nondestructive neurostimulation techniques. Despite the advances in conservative therapy of cancer pain, in many cases, a neurosurgical procedure is most efficacious in controlling carcinoma pain.

[Percutaneous cordotomy. Actual situation in pain surgery (author's transl)]. / La cordotomie percutanée. Sa place actuelle dans la chirurgie de la douleur.

A personal experience with 138 percutaneous cordotomies is presented. The results and complications are compared to those of 49 open cordotomies at C1-C2 level. It is concluded that the percutaneous technique has better results and less complications. Nevertheless the percutaneous cordotomy is sometimes hazardous and presents some inconvenience. For this reason the author prefers in certain cases open cordotomy in a modified microsurgical technique which is described. It is outlined that in the authors opinion cordotomy should be restricted to cancer pain.

Ly phenotype of lymphocytes producing murine migration inhibitory factor (MIF).

Murine lymphocytes from lymph nodes or peritoneal exudates were tested after treatment with various anti-Ly sera plus complement for their ability to produce MIF in response to stimulation with either antigen or mitogen. When remaining cells in the LN and PEC were stimulated with either Con A or PPD, respectively, it was found that cells of the Lyl set were primarily responsible for MIF production by T cells. This does not rule out the possibility that, under certain circumstances, other T cell sets may produce MIF or material with similar properties after stimulation by antigen.

Chronic electrical stimulation of the thalamic unspecific activating system in a patient with coma due to midbrain and upper brain stem infarction.

Chronic intermittent bipolar electrical stimulation of the left nucleus reticulatus polaris thalami was performed in a patient in a state of subcoma due to ischaemic infarction of wide medial parts of the midbrain, mainly the tegmentum, and the right-sided mediobasal parts of the forebrain. Stimulation immediately resulted in autonomic reactions and behavioural arousal reactions during the periods of stimulation. Longterm effect consisted of a rise in the level of clinical responsiveness for a period of seven weeks. A preexistent severe pneumonia disappeared completely after one week of stimulation and returned after seven weeks. The results are discussed on the basis of the pathoanatomical findings and of the physiological functions of the damaged as well as of the stimulated areas.

Alteration of some functional and metabolic characteristics of resident mouse peritoneal macrophages by lymphocyte mediators.

Resident mouse peritoneal macrophages were incubated in Sephadex G-100 fractions of supernates from concanavalin A-stimulated lymphocytes. A significant effect of the lymphocyte supernatant fractions containing mediators on macrophage 5'-nucleotidase, glucose-1 14C oxidation, cell maintenance, and migration is reported. The 5'-nucleotidase was depressed to an extent similar to that seen in activated macrophages obtained from Listeria-infected mice. On the other hand, glucose-1-14C oxidation was enhanced, but not to the same degree as seen in the counterparts in vivo. Whereas migration inhibitory factor (MIF) and cell adherence-augmenting activity were found in a number of adjacent fractions, the metabolic effects were found predominantly in a single fraction. Resident peritoneal macrophages or those elicited by the injection of a lymphocyte-derived chemotactic factor were more responsive with respect to the biochemical changes than caseinate-elicited macrophages. On the other hand, caseinate-elicited macrophages appeared to be more sensitive with respect to the effects of mediator(s) on cell retention. A possible dissociation between MIF and cell-adherence augmenting activity, on the one hand, and the entities that stimulate glucose-1-14C oxidation is reported, based on fractionation studies, and loss of the latter activity upon storage of lymphocyte supernates.

[A new and simple method for determining the position of the venous angle on the lateral angiogram (author's transl)]. / Eine neue und einfache Methode zur Lagebestimmung des Angulus venosus im seitlichen Angiogramm.

The authors describe a new and very simple method for the localisation of the venous angle on the lateral view of carotid angiography: the venous angle projects exactly on the midpoint of a line between the endobregma and the base of the external auditory meatus.

[Lesions of the cauda equina after dimer-X myelography (author's transl)]. / Akutes Kaudasyndrom nach Dimer X Myelographie.

The authors describe five cases of an uncommon complication after Dimer X Myelography consisting in a more or less complete lesion of the caudia equina. Up to the present only seven similar cases have been reported in the literature. The evolution and the clinical symptoms of these cases were similar to those reported by others. While in the cases presented the clinical outcome was favourable, with complete recovery in all cases, less favourable evolutions with definitive neurological symptoms are described by others.