Treatment of epileptic seizures in brain tumors: a critical review.

Epileptic seizures represent a common signal of intracranial tumors, frequently the presenting symptom and the main factor influencing quality of life. Treatment of tumors concentrates on survival; antiepileptic drug (AED) treatment frequently is prescribed in a stereotyped way. A differentiated approach according to epileptic syndromes can improve seizure control and minimize unwarranted AED effects. Prophylactic use of AEDs is to be discouraged in patients without seizures. Acutely provoked seizures do not need long-term medication except for patients with high recurrence risk indicated by distinct EEG patterns, auras, and several other parameters. With chronically repeated seizures (epilepsies), long-term AED treatment is indicated. Non-enzyme-inducing AEDs might be preferred. Valproic acid exerts effects against progression of gliomatous tumors. In low-grade astrocytomas with epilepsy, a comprehensive presurgical epilepsy work-up including EEG-video monitoring is advisable; in static non-progressive tumors, it is mandatory. In these cases, the neurosurgical approach has to include the removal of the seizure-onset zone frequently located outside the lesion.

Cerebral vasospasm following temporal lobe epilepsy surgery.

OBJECTIVE: Selective amygdalohippocampectomy (AHE) has been associated with postoperative cerebral vasospasm (CVS) in patients with medically intractable temporal lobe epilepsy. The incidence in temporal lobe resection (TLR) is unknown. This retrospective cohort study evaluates the incidence of and risk factors for the development of CVS in patients with TLR and AHE. METHODS: A total of 119 patients were included between 1998 and 2009. All patients were evaluated by standardized preoperative and postoperative transcranial Doppler sonography (TCD) evaluations and neurologic examinations. Postoperative CT scans were evaluated by an independent radiologist and the volume of bleeding within the resection cavity was quantified. RESULTS: Of 107 patients with longitudinal TCD data, 35 (32.7%) developed postoperative CVS. The incidence of CVS did not differ between patients with TLR and AHE. CVS was associated with female gender and a higher bleeding volume in the postoperative CT scan (p = 0.035 and 0.046). Patients with CVS showed a significantly higher incidence of postoperative neurologic signs and symptoms (48.6%) compared to patients without CVS (25%, p = 0.015). The mean length of stay was significantly prolonged in patients with diffuse CVS compared to patients with localized CVS or no CVS (28.8 ± 10.9, 24.2 ± 6.6, and 18.2 ± 6.1 days, p < 0.001). CONCLUSION: CVS is a frequent complication of surgery for temporal lobe epilepsy irrespective of the resection method. Important risk factors for the development of postoperative CVS are female gender and a higher amount of bleeding in the postoperative CT. Patients with CVS more frequently have neurologic signs and symptoms resulting in prolonged hospital stay.

Hippocampal abnormalities in malformations of cortical development: MRI study.

OBJECTIVES: Hippocampal abnormalities may coexist with malformations of cortical development (MCD). This cross-sectional MRI study aimed at categorizing hippocampal abnormalities in a large group of MCD and comparing MCD patients with (group W) and without (group W/O) hippocampal abnormalities. METHODS: Hippocampal anatomy, rotation, size, internal structure, and MRI signal alterations were assessed visually by 3 independent raters in patients with MCD and epilepsy. Four types of hippocampal abnormalities were examined in 220 patients (116 women, mean age 31 +/- 16.6, range 2-76 years): partially infolded/hypoplastic hippocampus (HH), hippocampal sclerosis (HS), malrotated hippocampus (MH), and enlarged hippocampus (EH). The commonest MCD in the cohort were focal cortical dysplasia (27%), polymicrogyria (PMG) (21%), developmental tumors (15%), and periventricular nodular heterotopia (PNH) (14%). RESULTS: Hippocampal abnormalities were seen in 69/220 (31%) patients: HH in 34/69 (49%); HS in 18/69 (26%); MH in 15/69 (22%); and EH in 2/69 (3%). PNH (21/30 [70%]) and PMG (22/47 [47%]) were most commonly associated with hippocampal abnormalities. Compared to the W/O group, patients in the W group had a higher rate of learning disability (W 41/69 [59%] vs W/O 56/151 [37%]; p = 0.003) and delayed developmental milestones (W 36/69 [52%] vs W/O 53/151 [35%]; p = 0.025); groups did not differ otherwise with regard to clinical presentation. HH was associated with symptomatic generalized epilepsies (11/34 [32%]) and high rate of learning disability (27/34 [79%]), neurologic deficits (25/34 [73%]), and delayed developmental milestones (23/34 [68%]). CONCLUSIONS: About a third of patients with malformations of cortical development had hippocampal abnormalities. Patients with hypoplastic hippocampus had the most severe clinical phenotype.

Integration of multimodality imaging and surgical navigation in the management of patients with refractory epilepsy. A pilot study using a new minimally invasive reference and head-fixation system.

OBJECTIVE: To review the experience with a new system (VBH system) for minimally invasive frameless stereotactic guidance, acting as a common platform to provide multimodal image integration and surgical navigation in a consecutive series of 25 patients who underwent surgery for drug-resistant seizures. METHODS: The usefulness of the VBH system for integrating all images to produce one dataset and for intraoperative instrument guidance and navigation was judged semiquantitatively in a three-tiered scale (+, ++, +++). Seizure outcome was classified according to Engel. RESULTS: The presurgical evaluation extended over 21.2 months (mean). A total of 141 registrations of images were performed (mean 5.6 per patient, range: 2 to 16). In 19 (76%) of 25 patients structural data fused with functional data were used for the presurgical workup. Six patients proceeded directly to navigated resection. Nineteen patients (76%) underwent invasive recording, of whom 13 underwent resective surgery. In seven patients (28%) the combination of multimodal image fusion and intra-operative stereotactic guidance was judged "essential" (+++) to remove the epileptogenic zone. Integration of all images to form one dataset was "essential" (+++) for decision making in 15 and "helpful" (++) in 4 patients (overall 76% of patients). Intraoperative use of frameless neuronavigation was "essential" (+++) in ten and "helpful" (++) in all remaining patients. Eighty percent of the patients achieved satisfactory seizure outcome after 1 year. CONCLUSION: The VBH system is a safe and effective non-invasive tool for repetitive imaging, multimodal image fusion and frameless stereotactic surgical navigation in candidates for epilepsy surgery.

Flexibility of head positioning and head fixation provided by a novel system for non-invasive maxillary fixation and frameless stereotaxy: technical note.

OBJECTIVE: The aim of this study was to demonstrate the flexibility in patient positioning and head fixation provided by a newly developed, minimally invasive upper jaw fixation device in combination with standard navigation software. TECHNIQUE: The Vogele-Bale-Hohner (VBH) headholder and the Stereotactic Intervention and Planning Laboratory (SIP-Lab) Innsbruck reference frame, were applied in epilepsy surgery requiring stereotactic guidance. The system can be adapted to various positioning and instrument guidance requirements. Instrument holders can be fixed either to a base plate or directly to the mouthpiece. When used together with a head clamp and a stabilizing arm, there are no restrictions on patient positioning. When used with the non-invasive headholder, only the supine position is well-suited for use with the described guidance instrumentation. The system can also be used with the head placed on the horseshoe headholder without altering navigation support. CONCLUSION: The VBH mouthpiece combined with an external registration frame is a flexible tool that permits patient positioning and neuronavigation with the head either fixed with a head clamp, or restrained non-invasively with a headholder, or not fixed at all. This might be advantageous within the context of epilepsy surgery.

Accuracy and clinical use of a novel aiming device for frameless stereotactic brain biopsy.

Aiming devices enable the use of neuronavigation systems for rigid instrument guidance mimicking the possibilities of a frame-based system without having a stereotactic frame affixed to the skull. The aim of the presented work was to investigate the phantom targeting accuracy of the Vertek aiming device (Medtronic Inc., Louisville, USA) and whether it can be safely and accurately applied in a concept of minimally invasive brain biopsy in which multi-modal image fusion, image-to-patient registration and head immobilization were based on a non-invasive vacuum mouthpiece. A plastic model of a head with 20 target beads broadly distributed around the head volume was used for determination of CT-based targeting accuracy. Every target was punctured 5 times totaling 100 needle positionings. Accuracy was evaluated on postoperative CT scans with the needles in place. The mean normal deviation (n = 100) was 1.5 +/- 0.8 mm and the mean angle of deviation was 1.1 +/- 0.7 degrees. In a preliminary clinical series in ten patients diagnostic biopsy sampling of intracranial lesions with a median diameter of 28 mm (range: 12-90 mm) could be achieved in all patients and no biopsy related complications were recorded. The experimental results showed a similar accuracy to frame-based stereotaxy. The device facilitates trajectory alignment via two pivot joints and the actual depth and location of the biopsy needle can be monitored. Within the limitations of a preliminary study, brain biopsy may be accurately and safely performed for lesions > or = 12 mm.

Electroclinical and imaging findings in ulegyria and epilepsy: a study on 25 patients.

PURPOSE: Ulegyria refers to cerebral cortex scarring, which results from a perinatal ischaemic brain injury. It presents with a characteristic gyral pattern: small circumvolutions with atrophy at sulci bottom and spared apex. Ulegyria is frequently associated with epilepsy, cerebral palsy and mental disability. We analysed electroclinical and MRI features in patients with ulegyria and epilepsy. PATIENTS AND METHODS: We reviewed 25 patients (14 males/11 females) with ulegyria and epilepsy from the database (about 5000 patients with epilepsy) of our unit. Patients were examined clinically, underwent high resolution MRI, EEG recordings, positron emission tomography, single photon emission computed tomography and neuropsychological testing. Two patients with refractory seizures underwent epilepsy surgery. RESULTS: Mean age of patients was 34 years (5-66) at the reassessment time. The majority (16/25, 64%) had a history of perinatal asphyxia. 15 patients had delayed developmental milestones; 20 had learning disabilities and five patients were severely disabled. Mean age at seizure onset was 4.2 years (1-18). 17 patients (68%) had medically intractable epilepsy. 11 patients (44%) had occipital lobe seizures. The majority (n = 24, 96%) had parieto-occipital lesions on MRI. In 13 patients (52%), ulegyria was bilateral. 12 patients (48%) had hippocampal sclerosis. Two patients underwent epilepsy surgery with an excellent postoperative outcome (Engel class IA and IC). CONCLUSION: Patients with ulegyria often have a history of perinatal asphyxia and present with pharmacoresistant seizures. Their presurgical assessment is complicated because of frequent dual pathology (hippocampal sclerosis) and bilateral lesions.

Outcome of adult patients with temporal lobe tumours and medically refractory focal epilepsy.

BACKGROUND: Tumours are a well-recognized cause of medically intractable epilepsies. Tumours represent the primary pathology in 10%-30% of patients undergoing surgical treatment for chronic epilepsy. This study examines the surgical and epileptological outcome of adults with temporal lobe tumoural epilepsy treated within a comprehensive epilepsy surgery programme. METHODS: Between 1999 and 2004, 99 consecutive patients have been operated for intractable temporal lobe epilepsy (TLE). Among these, 14 adult patients exhibited temporal lobe neoplasms associated with TLE. Every patient underwent a comprehensive presurgical evaluation including video-EEG monitoring, MRI, interictal PET scan, ictal SPECT and neuropsychological testing. Surgical strategies were determined in an interdisciplinary seizure conference and tailored to the findings of the presurgical evaluation. All patients were available for follow up at regular intervals after 3, 6, 12 months and yearly thereafter. Epileptological outcome was classified according to Engel [10] and the ILAE (International League Against Epilepsy)/systems [33]. FINDINGS: The surgical procedures performed were temporal lobe resection in 3 patients, extended lesionectomy in 4 and extended lesionectomy with resection of the temporomesial structures in 7. One patient with an astrocytoma grade III underwent a second and third operation for recurrent disease. Histological results: Astrocytoma 5 patients, ganglioglioma/gangliocytoma 5, oligodendroglioma 2, ependymoma 1 and dysembryoplastic neuroepithelial tumour (DNET) 1. Postoperative follow-up was performed after 12-74 months (mean 31). The outcome according to the Engel classification indicated class IA in 9 patients, class IC in 3, and 1 each in classes IIIA and IVA. Epileptological outcome according to the ILAE classification indicated class 1 (12 patients) and class 4 (2 patients). Surgical mortality was zero and mild permanent neurological deficits due to surgery were seen in 2 patients. Postoperatively 3 patients showed a homonymous quadrantanopia. CONCLUSIONS: Patients with drug resistant epilepsy and temporal lobe tumours should undergo evaluation in dedicated epilepsy surgery programmes.

Gyratory seizures revisited: a video-EEG study.

PURPOSE: Gyratory seizures (GSs) have been rarely described in generalized as well as in focal epilepsies. They were defined as a rotation around the body axis during a seizure for at least 180 degrees. The mechanisms of generation are unknown and have been discussed controversially. The aim of this investigation was to further delineate seizure semiology and assess a possible lateralizing and localizing value of GSs. METHODS: The authors screened 277 consecutive patients with intractable epilepsies referred to a University Hospital for presurgical evaluation between 1998 and 2004 for GSs: 169 had temporal lobe epilepsy (TLE), 47 frontal lobe epilepsy (FLE), 38 generalized epilepsies (GE), and 23 had extratemporal or multifocal epilepsy. RESULTS: Twelve patients showed gyratory movements in 17 seizures. Eight had FLE and four TLE (p < 0.001). In 58% (7/12), the gyratory movement was initiated by a forced versive movement of the head followed by a rotation toward the contralateral side of seizure onset. In 42% (5/12), the gyratory movement was not preceded by a forced head version. In these seizures, the direction of the rotation was toward the side of seizure onset. CONCLUSIONS: The direction of rotation lateralizes seizure onset zone in focal epilepsy depending on the seizure evolution: 1) gyratory seizures (GSs) starting with a forced version of the head ensuing into a body rotation lateralize seizure onset zone contralateral to the direction of rotation. 2) In GSs without a preceding gyratory forced head version, the direction of rotation is toward the side of seizure onset. GSs occur more frequently in frontal lobe epilepsy than temporal lobe epilepsy, while none of our patients with GSs had generalized epilepsies.

Peri-ictal water drinking lateralizes seizure onset to the nondominant temporal lobe.

The authors describe seven patients with medically refractory temporal lobe epilepsy whose seizures were associated with peri-ictal water drinking behavior. Presurgical evaluation, including video-EEG monitoring, MRI, SPECT, and neuropsychological testing, revealed a seizure onset in the nondominant temporal lobe. All patients had an excellent outcome after epilepsy surgery. Peri-ictal water drinking may represent a lateralizing sign indicating seizure onset in the nondominant temporal lobe.

Asymmetric termination of secondarily generalized tonic-clonic seizures in temporal lobe epilepsy.

In patients with secondarily generalized tonic-clonic seizures (sGTCS) an asymmetric termination of the clonic phase can be observed. The authors systematically analyzed this phenomenon in patients with temporal lobe epilepsy (TLE). Thirty-nine sGTCS from 29 patients with TLE who underwent successful epilepsy surgery were analyzed, in addition to a prospectively collected group of 28 patients with TLE who had 35 sGTCS. The clonic phase of sGTCS did not end synchronously in 65.7% of all patients and in 59.4% of all seizures. In 79.3% to 80% this was ipsilateral to the hemisphere of seizure onset, and there was excellent interobserver agreement.

Deep wound infection after vagus nerve stimulator implantation: treatment without removal of the device.

Effective treatment of deep wound infection without removal of a previously implanted foreign body is difficult. The Neurocybernetic Prosthesis (NCP) System (Cyberonics Inc., Webster, TX, U.S.A.), implanted for vagus nerve stimulation in patients with medically refractory epilepsy, uses coil-like electrodes placed around the left vagus nerve after exposure of the nerve in the carotid sheath. Infection within this compartment endangers the contained structures and makes removal of the system hazardous. We report the case of one patient implanted with the NCP who underwent successful open wound treatment without removal of the system. A 35-year-old man had local signs of wound infection 5 weeks after implantation of a vagus nerve stimulator. Systemic signs of infection were absent. C-reactive protein was slightly elevated, but all other laboratory values were normal. After open wound debridement and thorough rinsing with bacitracin-containing solution, the wound was packed with 3% iodoformized gauze. The NCP was left in place. Systemic antibiotic therapy with fosfomycin and cefmenoxim was started. Cultures confirmed an infection with Staphylococcus aureus. The wound was rinsed daily with 3% hydrogen peroxide solution and 5% saline until cultures were sterile and granulation tissue started to fill the wound. Delayed primary closure was performed 2 weeks later. Wound healing was accomplished without removal of the device. No signs of recurrent infection were observed during a follow-up of 1 year. Open wound treatment without removal of the implanted vagus nerve stimulator is feasible in cases of deep cervical wound infection and can be an alternative if removal of the device appears hazardous.

Posterior-fossa haemorrhage after supratentorial surgery--report of three cases and review of the literature.

We present clinical details of three patients with posterior fossa haemorrhage after supratentorial surgery and discuss possible pathomechanisms of this rare complication. All patients were males of advanced age. Two patients presented with a history of hypertension. In all patients the occurrence of haemorrhage was associated with loss/removal of large amounts of cerebrospinal fluid (CSF) either intra-operatively (one patient undergoing aneurysm surgery) or postoperatively (all three patients: drainage of subdural hygromas or chronic subdural haematomas in two, external ventricular drainage in one patient). Treatment consisted in haematoma evacuation and/or external ventricular drainage. Two patients died, one patient recovered completely. Although haematomas distant from a craniotomy site are a well known entity, a review of the literature identified only 25 published cases of posterior fossa haemorrhage after supratentorial procedures in the CT era. Most often disturbances of coagulation, positioning of the patient and episodes of hypertension have been associated with this complication. Only one author described the occurrence of a haemorrhage after drainage of a supratentorial hygroma. We suggest that the loss of large amounts of CSF intra-operatively and post-operatively may lead to parenchymal shifts or a critical increase of transmural venous pressure with subsequent vascular disruption and haemorrhage.

Hypocapnia reverses the fentanyl-induced increase in cerebral blood flow velocity in awake humans.

Investigations on the effects of opioids on cerebrovascular dynamics have repeatedly demonstrated mild to moderate increases in cerebral blood flow velocity in the middle cerebral artery (CBFVMCA), cerebral blood flow, and cerebrospinal fluid pressure in humans and animals. However, the influence of hypocapnia on these fentanyl effects has not been investigated. We compared mean CBFVMCA during normo- and hypocapnia before and after administration of fentanyl (2.5 micrograms/kg i.v.) in 20 awake humans. During normocapnia (end-tidal carbon dioxide [ETCO2] 40 mmHg) fentanyl significantly increased mean CBFVMCA (60 +/- 10 cm/s vs. 81 +/- 12 cm/s [mean +/- SD]; p < 0.01), whereas during hypocapnia (ETCO2 25 mmHg) mean CBFVMCA values were identical (40 +/- 7 cm/s vs. 40 +/- 7 cm/s) before and after fentanyl administration. These results confirm previous findings that administration of fentanyl increases CBFVMCA, but, more importantly, clearly indicate that hypocapnia reverses this potentially undesirable effect.

Transcutaneous pressure-adjustable valves and magnetic resonance imaging: an ex vivo examination of the Codman-Medos programmable valve and the Sophy adjustable pressure valve.

OBJECTIVE: We investigated the compatibility of magnetically adjustable cerebrospinal fluid valves with clinical magnetic resonance imaging. Torque acting on the valves, subjective sensations of valve-carrying volunteers, extension of artifacts on acquired images, changes in valve pressure setting, and accurate valve function after repeated exposure to the magnetic field were tested. METHODS: Two externally adjustable differential pressure valves, i.e., the Codman-Medos programmable valve (Medos S.A., Le Locle, Switzerland) (n = 5) and the Sophy programmable pressure valve (Sophysa, Orsay, France) (Model SP3, n = 4; Model SU8, n = 3; and Model SM8, n = 2) were exposed to the magnetic fields of 1.5-T clinical scanners. Ferromagnetic properties were investigated according to an established protocol. Subjective sensations during positioning and scanning and image artifacts were investigated using standard clinical imaging protocols. Changes in opening pressure setting during repeated magnetic field exposure were examined using valves affixed to a dummy. RESULTS: Deflection forces measured 117 dynes in the Medos valve, and 2439 (Model SP3), 2172 (Model SU8) and 1914 (Model SM8) dynes in the Sophy valves. Torque during positioning and during imaging was reported for the Sophy valves. Distortion of the magnetic field with artifacts on acquired images ranged 6 x 6 x 12 cm around the Sophy valve and 4 x 4 x 4 cm around the Medos valves. Artifact extension increased with longer TE times on T2-weighted images and when using gradient-echo sequences. The pressure setting of the Medos valves did not change in 31 of 88 tests. Below 170 mm H2O, the maximal disadjustment was 60 mm H2O in each direction. Minor changes of the pressure setting were observed at 50 and 30 mm H2O. In 11 of 15 tests at 200 mm H2O, the setting after magnetic field exposure was below 30 mm H2O. One Medos valve could no longer be programmed after being exposed four times to the static magnetic field. Sophy valves remained at or changed to "high" in 68 of 81 tests and to "low" in 9. All Sophy valves exhibited paramagnetic behavior after the tests. All remained programmable. Observed changes always occurred within the safety area of the magnet. CONCLUSION: Subjective disturbances resulting from paramagnetic valve behavior are absent in Medos valves and are minor in Sophy valves. Image artifacts require careful planning of valve position. Artifacts observed in magnetic resonance imaging are less disturbing than those observed in computed tomography. Medos valves are more stable regarding disadjustment than are Sophy valves. Radiological control of valve setting after exposure to the magnetic field is mandatory in both. The 0.5-mT safety line encircling the area that patients with pacemakers should not enter is a useful safety borderline for patients with pressure-adjustable valves. Failure of the programming mechanism of one Medos valve after several exposures to the magnetic field requires clarification.

Quadriplegia after lumbar disc surgery. A case report.

STUDY DESIGN: Case report. OBJECTIVE: To report a case of quadriplegia after surgery in the prone position for a herniated lumbar disc. SUMMARY OF BACKGROUND DATA: Ischemia in the vascular territories of the vertebral arteries after back surgery in the prone position is rare. Degenerative changes of the cervical spine or decreased blood flow to the head with mechanical vessel obstruction during extreme neck movements, systemic hypotension, and thromboembolism have mostly been implicated in the pathogenesis. METHODS: The case of a 33-year-old man undergoing surgery for an unilateral single level disc herniation at L4-L5 is presented. Within a few hours after surgery he developed quadriplegia and signs of occipital lobe dysfunction. He underwent magnetic resonance imaging investigation. Therapy included arterial blood pressure control, low molecular dextran, dexamethasone, bladder catheterization, and physiotherapy. RESULTS: Magnetic resonance imaging demonstrated intramedullary ischemic changes in the cervical spinal cord and at the borderline between anterior and posterior circulation. Outcome after 2 years is fair regarding the severe initial deficit-the patient walks alone with a cane and bladder function is under control. He is employed in a sedentary job. CONCLUSIONS: The authors believe that a temporary mechanical occlusion of a vertebral artery led to stasis, formation of thrombi, and subsequent embolism in the vertebrobasilar vascular territory. Extreme head rotation and neck extension is to be avoided in the prone position.

The interface between ionomer cement and bone in the porcine cervical spine.

The interface between bone and ionomer cement has been studied in twelve young adult pigs 1-6 months after anterior cervical discectomy, removal of adjacent end plates and grafting of the bone defect with ionomer cement. Methods used to study the interface were fluorescence microscopy, scanning electron microscopy, electron microprobe analysis and radiological investigation. The interface in all animals consisted of collagenous tissue. The amount of collagenous fibres was related to the amount of residual movement within the motion segment: animals undergoing anterior plating after reconstruction of the bone defect presented with more or less compactly organized collagenous tissue. Sequential fluorochromic marking of osteoid formation revealed a vital bone bed around the interface but no signs of direct bone apposition to the ionomer cement plug. No signs of toxicity or graft rejection were noted. Ionomer bone cement contrary to experimental and clinical experience induces the formation of a connective tissue layer of different density in the porcine cervical spine.

Management of spontaneous extramedullary spinal haematomas: results in eight patients after MRI diagnosis and surgical decompression.

Spinal cord compression due to extradural and subdural haemorrhage is a neurosurgical emergency. Differences in clinical presentation in relation to localisation of the haematoma, value of MRI as a diagnostic tool, surgical treatment, and prognosis were investigated in a retrospective case series of eight patients with extradural (n = four) and subdural (n = four) haematomas. Results of MRI were compared with operative findings and proved to be of high sensitivity in defining the type of bleeding and delineating craniocaudal extension and ventrodorsal location. Surgical treatment by decompressive laminectomy, haematoma evacuation, and postoperative high dose corticosteroids resulted in resolution of symptoms in five patients and improvement in the clinical situation in two patients. One patient with a chronic subdural haematoma had a second operation because of arachnoidal adhesions. One patient presented with a complete cord transection syndrome due to an acute subdural haematoma and remained paraplegic. It is concluded that prompt, reliable, and non-invasive diagnosis by MRI leads to efficient surgical treatment and a favourable outcome in this rare condition.

Therapy of glioblastoma multiforme: a cumulative experience of 10 years.

PURPOSE: Comparison of the effect of different therapeutic modalities on survival time of patients with glioblastoma multiforme operated on during the last decade (1980-1990). PATIENTS AND METHODS: The records of 157 consecutive patients with the histological diagnosis of glioblastoma multiforme were analysed for survival with respect to age of patients, extent of surgery, influence of re-operation and adjuvant postoperative treatment. The latter included fractionated radiotherapy, chemotherapy (BCNU. CCNU with Vincristine) and photodynamic therapy (PDT). RESULTS: Analysis of variance showed a significant effect for survival after macroscopically radical surgery (p = 0.005), postoperative radiotherapy (p < 0.001), chemotherapy (p < 0.01). Low age (p < 0.05) and a postoperative Karnofsky performance score (KPS) > or = 60 (p < 0.001) had a positive influence: the site of tumour and pre-operative presence of seizures had no significant influence (p > 0.1) on survival time. CONCLUSION: We conclude that the current adequate management of glioblastoma multiforme should include surgical resection followed by adjuvant treatment such as radiotherapy and chemotherapy.