[Clinical experience with various shunt systems in normal pressure hydrocephalus]. / Klinische Erfahrungen mit verschiedenen Shuntsystemen beim Normaldruckhydrozephalus.

In patients with normal pressure hydrocephalus in the late stage conventional differential valves have the disadvantage that they open abruptly while changing the body position to the vertical line and that they can therefore induce a suction on the ventricles of the atrophic brain. Can these disadvantages and overdrainage complications be minimized by hydrostatic valves? In 117 patients diagnosed for normal pressure hydrocephalus we have implanted 47 Cordis Standard Valves (CSV), 20 Cordis Orbis Sigma Valves Type I (OSV) and 50 Miethke Dual Switch Valves (DSV). 95 patients (36/19/40) could be re-evaluated by means of a control examination. Normal pressure hydrocephalus was graduated according to the results of the intrathecal infusion test in an early and late stage. According to our NPH-Recovery-Rate and to the clinical grading of normal pressure hydrocephalus by Kiefer and Steudel we compared the post-operative results of each group of patients. There were no statistical differences in mechanical and infectious complications between the different valve types. We found significant differences in overdrainage and subdural hematomas. 4 patients (11%) with a CSV, 5 patients (26%) with an OSV and 2 patients (5%) with a DSV had a decrease of the ventricular width visualised in the CT. Of those patients 2 (6%) with a CSV, 3 patients (16%) with an OSV and 1 patient (3%) with a DSV developed clinical symptoms. The course of the disease in patients with normal pressure hydrocephalus is influenced by the stage of the disease--degree of cerebral atrophy--and also by the implanted valve type. The high amount of overdrainage complications and subdural hematomas in the Cordis Orbis Sigma Valve Type I group is an argument against its use. Our clinical experiences with the Miethke Dual Switch Valve show that this hydrostatic valve is of advantage for patients with a normal pressure hydrocephalus.

Clinical experiences with the dual-switch valve in patients with normal pressure hydrocephalus.

In patients with normal pressure hydrocephalus (NPH) we compared the postoperative results reference to the implanted valve type. In 117 patients diagnosed with normal pressure hydrocephalus there was placement of 47 Cordis Standard valves (CSV), 20 Cordis Orbis Sigma valves type I (OSV) and 50 Miethke Dual-switch valves (DSV). Ninety-five patients (36/19/40) were re-evaluated. Normal pressure hydrocephalus was graduated according to the results of the intrathecal infusion test in an early and late stage. There were no statistical differences in mechanical and infective complications between the different valve types. We found significant differences in overdrainages and subdural hematomas. Two patients (6%) with a CSV, 3 patients (16%) with an OSV and 1 patient (3%) with a DSV developed clinical symptoms due to this. The course of disease in patients with NPH is influenced by the stage of disease--degree of cerebral atrophy--and also by the implanted valve type. The great amount of overdrainage complications and subdural hematomas in the Cordis Orbis Sigma valve group may be an argument against this valve. Our clinical experiences with the Miethke Dual-switch valve show that this hydrostatic valve may be advantageous for patients with NPH.

Signs, symptoms and course of normal pressure hydrocephalus in comparison with cerebral atrophy.

Between May 1982 and January 1997 we investigated 200 patients for normal pressure hydrocephalus (NPH) by performing an intrathecal infusion test. 168 patients (84%) presented with the clinical syndrome of gait ataxia, dementia and urinary incontinence, the so called Adams triad. In 107 patients (54%) the diagnosis of a NPH could be confirmed. Of these, 102 patients (95%) underwent a shunt operation. In a follow-up (7 month and 3 years later) we interviewed the patients or their relatives about the progression of the disease. At those time intervals we could evaluate the improvement after shunt operation or infusion test. In our experience gait ataxia is the guiding sign of NPH. Regarding dementia we could not find a significant difference compared to cerebral atrophy. Urinary incontinence can be characterized as a symptom of late stage NPH. The complete Adams triad should not be overestimated in differential diagnostic considerations. Subdivision of NPH into an early stage and a late stage allows one to conclude prognostic evaluations about the course of the disease. Patients with an early stage NPH reported at the follow-up an improvement of their symptoms after shunt operation in 65 percent and those with a late stage NPH in 50 percent. The computer aided infusion test allows a safe differentiation between patients with NPH and those with cerebral atrophy.

Diagnostic in normal pressure hydrocephalus: A mathematical model for determination of the ICP-dependent resistance and compliance.

The internationally accepted calculation methods concerning cerebrospinal fluid dynamics proceed from a pressure independent resistance to cerebrospinal fluid outflow. In a new model we focus our attention on the pressure dependency of resistance. In our calculation model we are monitoring the complete pressure course p(t) over the time during and after the infusion. The comparison of the pressure rise On(p) during the infusion and the descent Off(p) after the infusion at the same pressure level allows one to construct all formulas for the compliance C(p) and resistance R(p). The computerized analysis of the results of the intrathecal infusion test using our mathematical computation leads to a simplification of this investigation. The simultaneous measurement of the resistance and compliance during a single investigation allows one to minimize the patient's discomfort. In contrast to the classical methods it is not necessary that the ICP reaches a plateau. Our mathematical method diverges with the description of a pressure dependent slope of the function for the resistance from the static examination models. For that we are able to take the non-linearity of the cerebrospinal fluid resorption into consideration.

[Psychophysiology, signs and symptoms of disease the course of normal pressure hydrocephalus]. / Pathophysiologie, Klinik und Krankheitsverlauf beim Normaldruckhydrozephalus.

Between May 1982 until January 1997 we investigated 200 patients suspected for normal pressure hydrocephalus (NPH) by performing an intrathecal infusion test. According to our experiences gait ataxia is the leading symptom of NPH. Regarding dementia we could not find a significant difference compared to cerebral atrophy. Bladder incontinence can be characterised as a symptom of late-stage NPH. The complete Hakim trias should not be overestimated in differential diagnostic considerations. Graduation of NPH and cerebral atrophy after the results of the infusion test in an early and late stage enables prognostic evaluation of the course of disease. Patients with NPH in an early stage report in the follow-up on an improvement of their symptoms after shunt operation (65 percent of patients), whereas 50 percent of the patients with late stage NPH were improved. The computer-aided infusion test allows secure differentiation between patients with NPH and those with cerebral atrophy.

[Diagnosis of normal pressure hydrocephalus. A calculation model for determining intracranial pressure-dependent resistance and compliance]. / Zur Diagnostik des Normaldruckhydrozephalus. Ein Berechnungsmodell zur Ermittlung der ICP-abhängigen Resistance und Compliance.

Computer-aided analysis of the results of the intrathecal infusion test using our mathematical computation leads to simplification of this investigation, and therefore normal pressure hydrocephalus is more easily diagnosed. Simultaneous measurement of resistance and compliance during a single investigation allows the exertion of the patients to be minimized. In contrast to classic methods it is not necessary that the ICP reaches a plateau. Our mathematical method diverges with the description of a pressure-dependent slope of the function for the resistance from the static examination models. For that we are able to take the non-linearity of the cerebrospinal fluid resorption into consideration. The intrathecal infusion tests is a reliable diagnostic method for measuring resistance and compliance in patients suspected of having normal pressure hydrocephalus.

Involvement of chromosome 22 in ependymomas.

We have karyotyped a total of twelve ependymomas using GTG-banding including seven for which preliminary results have already been published. One case showing hyperdiploid main line with two marker chromosomes was further analyzed by nonisotopic chromosome in situ suppression hybridization. It was shown that the marker chromosomes consisted of 1q, 14q and 1q, and 22q. The possible role of chromosome 22 in ependymomas and the usefulness of fluorescence in situ hybridization for cytogenetic analysis in tumor investigation are discussed.

[Surgical outcome after severe craniocerebral trauma in childhood and adulthood. A comparative study]. / Operationsergebnisse nach schwerem Schädel-Hirn-Trauma im Kindes- und Erwachsenenalter. Eine Vergleichsstudie.

During a period of 15 years 1123 patients were operated on for severe head injury in our Department of Neurosurgery. We evaluated 936 patients (83%) on the basis of the Glasgow coma scale and the Glasgow outcome scale and allocated them into four groups by diagnosis and also grouped them by age. The 170 patients in the groups of children and adolescents (15%) were compared with the adults, and the features characterizing the causes of the accidents and the prognosis were analysed. Young patients and adults with epidural haematomas or perforating head injuries had a better prognosis than patients with acute subdural haematomas or brain contusions. The postoperative results after severe head injuries in children and adults were the same as in the group with an initial rating of 3-5 points and 9-15 points on the Glasgow coma scale. Only the group of children with 6-8 points on the Glasgow coma scale on admission had better results than the adults. The reason for this might be the greater plasticity of the brain in childhood.

Age-related nonrandom chromosomal abnormalities in human low-grade astrocytomas.

We report a cytogenetic investigation of 55 low-grade astrocytomas in 52 patients, 15 children and 37 adults. In addition to numerical aberrations such as trisomy 7 and gonosomal losses, we found structural and/or numerical aberrations of chromosome 1 in eight astrocytomas. There was a striking difference between the rearranged chromosomes in pediatric and adult patients. Whereas the pediatric tumors revealed monosomies 1p with accompanying trisomy 1q, the astrocytomas in adults showed partial or complete monosomies 1q.

Karyotypes in 90 human gliomas.

Cytogenetic studies were performed on 90 human gliomas including 26 astrocytomas, 12 oligodendrogliomas, three oligo-astrocytomas, seven ependymomas, eight pilocytic astrocytomas, and 33 malignant gliomas (anaplastic astrocytomas and glioblastomas). The most common abnormalities were trisomy 7 in 23 cases, monosomy 22 in 15 cases, losses of the Y chromosome in 19 of 50 male cases, and losses of the X chromosome in 10 of 39 female cases. There are evident differences between the particular subgroups of gliomas. Monosomy 10 and double minutes are typical for malignant gliomas. The 58 determined chromosomal breakpoints were located on 45 different sites. Chromosomes 1, 9, 6, 3, 10, and 17 were predominantly involved.

[Interventional radiology in neurosurgery--on the use of endovascular balloon occlusion]. / Interventionsradiologie in der Neurochirurgie--zum Einsatz der endovaskulären Ballonokklusion.

A report is given on our experience gained in the introduction of the method of detachable microballoon catheters in the sense of the intervention neuroradiological operative technique. Twenty patients with arteriovenous angiomas, bag-like aneurysms, a carotid Sinus vernosus fistula and intracranial tumours rich in blood vessels were treated according to this method. Adjoining procedures such as embolisation are discussed.

[Spontaneous and surgical extra-intracranial anastomosis following bilateral occlusion of the internal carotid artery]. / Spontane und operative extra-intrakranielle Anastomosierung nach Verschluss der A. carotis interna beidseits.

A report is given on a case of bilateral carotid occlusion in which on one side a sufficient blood supply of the right hemisphere developed spontaneously via extra-intra-cranial anastomoses. On the opposite side, after proving an insufficient blood supply, an extraintracranial arterial bypass between the parietal branch of the A. temporalis superficialis and the cortical A. angularis was established micro-neurosurgically. The result was a reperfusion of the left aspect of the media and a clinical improvement of the neurological symptoms.

[Radionuclide angiography in the functional assessment of surgical extra- and intracranial vascular anastomoses]. / Radionuklidangiographie in der Funktionsbeurteilung operativer extra-intrakranieller Gefässanastomosen.

Extra-intercranial arterial vascular anastomosing is a surgical form of treatment in selected patients with ischemic cerebral diseases. For the demarkation of the indication for an operation and for the objectification of the functional results cerebrovascular radionuclide angiography was carried out in seven patients with cerebrovascular insufficiency before and after the bypass operation. The non-invasive method only requires an intravenous bolar radionuclide application. It permits a well reproducible appraisal of the regional cerebral blood flow. The best functional results of the shunt operation were observed in the radionuclide angiogram of patients with pronounced focal perfusion reductions. Functionally unsatisfactory results were obtained with low-degree diffuse perfusion reductions of one hemisphere. The results permit to derive criteria for the surgical indication.

[Extra-intracranial arterial bypass for cerebral trauma]. / Extra-intrakranieller arterieller Bypass beim zerebralen Insult.

A report is given on a young patient with a cerebral haemorrhage due to an occlusion of the A. carotis interna and the median main stem in which a regression of the one-sided symptoms could be achieved by a microneurosurgical establishment of an extra-intracranial anastomosis. The improvement of the cerebral perfusion could be objectivated angiographically and scintigraphically. The case shows that the prognosis of the cerebro-vascular lesion, especially in young and middle-aged patients, can be improved by surgical formation of collaterals. This gives hope for a further development of this method of treatment.

[Spontaneous ventriculocisternostomies]. / Die spontanen Ventrikulozisternostomien.

A pantopaque ventriculogram is used to demonstrate spontaneous ventriculocisternostomy over the r. suprapinealis in a patient with benign occlusion of the aqueduct. Clinical remission corresponds to sufficient spontaneous liquor drainage. Thus, a total of thirteen real perforations of the third ventricle have so far been described in the literature in addition to nine complete lateral ventricular ruptures. The differences between incomplete ventricular wall ruptures, ventricular diverticula, and ventriculocisternostomies are discussed.

[Traumatic carotid aneurysm in the region of the base of the skull with life-threatening hemorrhage into the nasopharyngeal space]. / Traumatisches Karotisaneurysma im Bereich der Schädelbasis mit lebensbedrohlicher Blutung in den Nasen-Rachen-Raum.

The author reports on a typical case of a traumatic aneurysm of the internal carotid artery with life-threatening bleeding which could be cured. Picture of the disease, diagnosis, and possibilities of treatment are discussed.

[Current status of diagnosis of the cerebrospinal-fluid space using Amipaque (metrizamide)]. / Aktueller Stand der Diagnostik des Liquorraums mit Amipaque (Metrizamide).

A report is given on 73 examinations using Metrizamide (8 thoracolumbar myelographies, 18 ventriculographies, 47 suboccipital myelographies) under consideration of the latest literature. Subsequent systematic EEG-controls were carried out in 52 patients. Exact observance of the indication, adequate dosage, optimum preparation and after-treatment of the patients as well as a appropriate operation technique can limitate the vegetativ side-effects and avoid rarely occurring serious complications. Publications in the literature as well as our own experiences stress the excellent representation of the details of the ventricular system and the spinal subarachnoid space.