Surgical treatment of spontaneous spinal cerebrospinal fluid leaks.

OBJECT: Spontaneous spinal cerebrospinal fluid (CSF) leaks are an increasingly recognized cause of intracranial hypotension and may require neurosurgical intervention. In the present report the authors review their experience with the surgical management of spontaneous spinal CSF leaks. METHODS: Between 1992 and 1997, 10 patients with spontaneous spinal CSF leaks and intracranial hypotension were treated surgically. The mean age of the seven women and three men was 42.3 years (range 22-61 years). Preoperative imaging showed a single meningeal diverticulum in two patients, a complex of diverticula in one patient, and a focal CSF leak alone in seven patients. Surgical exploration in these seven patients demonstrated meningeal diverticula in one patient; no clear source of CSF leakage could be identified in the remaining six patients. Treatment consisted of ligation of the diverticula or packing of the epidural space with muscle or Gelfoam. Multiple simultaneous spinal CSF leaks were identified in three patients. CONCLUSIONS: All patients experienced complete relief of their headaches postoperatively. There has been no recurrence of symptoms in any of the patients during a mean follow-up period of 19 months (range 3-58 months; 16 person-years of cumulative follow up). Complications consisted of transient intracranial hypertension in one patient and leg numbness in another patient. Although the disease is often self-limiting, surgical treatment has an important role in the management of spontaneous spinal CSF leaks. Surgery is effective in eliminating the headaches and the morbidity is generally low. Surgical exploration for a focal CSF leak, as demonstrated on radiographic studies, usually does not reveal a clear source of the leak. Some patients may have multiple simultaneous CSF leaks.

Cerebellar astrocytoma: experience with 54 cases surgically treated at the Mayo Clinic, Rochester, Minnesota, from 1978 to 1990.

A comprehensive review of the literature has shown that the treatment of choice for cerebellar astrocytomas has primarily been gross-total resection of the mass and gross-total resection of the enhancing portion of pilocytic astrocytomas. Most large scale studies of postresection survival rates of patients with cerebellar astrocytomas were conducted when computerized tomography (CT) and magnetic resonance (MR) imaging were not readily available. It has been shown that postoperative CT scans or MR images are more reliable than the surgeon's estimate of the degree of tumor resection at the time of surgery. It is not possible, therefore, to make an accurate determination regarding a postresection prognosis based on the degree of suspected tumor resection without the availability of appropriate radiographic imaging. In this study, the authors retrospectively evaluated the treatment of 54 patients with cerebellar astrocytoma who underwent surgery at the Mayo Clinic in Rochester, Minnesota, from 1978 through 1990. Preoperative and postoperative CT scans or MR images were available in all 54 patients.

A brain-tumor model utilizing stereotactic implantation of a permanent cannula.

A tumor model involving stereotactically implanted culture-reared tumor cells is presented. Stainless steel cannulas were stereotactically and permanently implanted into the caudate nucleus of 30 rats. The animals were separated into two groups. In Group I, 15 animals received a 10-microliters injection containing 10(6) C6 glioblastoma cells (five rats), 10(6) Walker 256 breast carcinoma cells (five rats), or cell medium (five rats). The coordinates were A(+1.5), L(+3.0), and DV(-5.0). In Group II, the coordinates were changed to A(+1.0), L(+3.0), and DV(-5.0) and the same number of rats received a 1-microliter injection containing 10(5) cells of each tumor in an attempt to produce more focal tumors. Two weeks after implantation, brain sections were stained with cresyl violet and a subset was stained for glial fibrillary acid protein (GFAP). A computerized morphometric analysis system was used to quantify tumor size. In Group I, the mean C6 tumor areas (+/- standard error of the mean) at specific coordinates were (in sq mm): A(+4.7) 0.4 +/- 0.2; A(+3.7) 3.5 +/- 1.1; A(+2.7) 5.7 +/- 1.7; A(+1.7) 9.5 +/- 2.3; A(+0.7) 7.5 +/- 3.2; A(-0.3) 3.7 +/- 2.9; and A(-1.3) 0.3 +/- 0.3. A nearly identical tumor mass and extension into the brain was produced in rats injected with Walker 256 cells. Similar C6 tumor areas were indicated in adjacent sections stained with cresyl violet and GFAP. Tumor was found in the caudate nucleus in all 10 rats, but not in the nucleus accumbens, fornix, or hippocampus. In Group II animals, tumor magnitude and extension into the brain were greatly reduced. The 10(6) cells in the 10-microliters volume was the most reliable tumor load for obtaining uniform tumors in different animals. The similarity of tumor distribution across different animals was indicated by the low variance of tumor area at specific anteroposterior coordinates. Reproducible and well-circumscribed caudate nucleus tumors were produced using this stereotactic procedure.

C6 glioma cell invasion and migration of rat brain after neural homografting: ultrastructure.

C6 tumor cells (10(6] were grafted as suspensions into freshly made implantation pockets in rat host cerebral cortex. Specimens were prepared for transmission and scanning electron microscopy 1 to 7 days postimplantation (DPI). By 3 DPI vacuolated C6 cells had migrated on or invaded the host brain. C6 cells were observed on the glia limitans on the surface of the brain, in the corpus callosum, subependymal space, and perivascular space and had invaded the cortex under the implantation pocket. In addition to the tumor mass that was observed under the implantation pocket, by 7 DPI individual C6 cells had migrated into the corpus callosum and internal capsule. Migrated C6 cells were observed in a perineuronal position in the hippocampus and other gray matter structures inferior to the corpus callosum. Micropockets were found around each C6 cell and the processes of these cells had replaced host parenchyma. The preferred routes of migration were on basal lamina and parallel and intersecting nerve fiber bundles. Invasion occurred through gray and white matter. The movement of homografted C6 cells in the brain suggests that these cells actively migrate as individual cells in addition to invading as a mass.

[Pseudotumor of the supraclavicular fossa]. / Lo pseudotumore della fossa sovraclaveare.

The authors focus on a physiopathologic manifestation, most often misdiagnosed, which present as a "lipomatous-like mass in the supraclavicular fossa". This is generally at the origin of sophisticated radiologic tests and, not infrequently of useless biopsies. The paper analyzes the different reasons leading, alone or in combination, to the phenomenon by which the mediastinal fat is pushed toward regions where no limits anatomic structures exist, such as the supraclavicular fossa. Knowledge of the above causes, together with a careful physical examination plus a standard postero-anterior-X-ray can easily lead to a correct diagnosis of "pseudotumor of the supraclavicular fossa", avoiding costly and needless diagnostic and therapeutic interventions.

[Problems of immunological monitoring and lung excision for carcinoma]. / Problemi de monitoraggio immunologico ed exeresi polmonare per carcinoma.

Following a number of remarks on the desirability of introducing into the practice of bronchopulmonary cancer surgery certain immunological ideas, a monitoring programme to be adopted in candidates for lung exeresis and for their subsequent monitoring is presented. The data to emerge thus far may be correlated fairly precisely with the prognosis and from this point of view their use in the selection of patients to be operated might be hypothesised.