Experience with neurocysticercosis in the UK: correct diagnosis and neurosurgical management of the small enhancing brain lesion.

Neurocysticercosis is a major cause of epilepsy and other neurological morbidity in endemic areas of the world but is exceptionally rare in the West. We have recently had experience of eight patients with this condition, seven presenting with epilepsy and single or multiple small, enhancing parenchymal lesions and one with hydrocephalus caused by a midbrain lesion. One lesion was stereotactically excised after it persisted, but in five other cases spontaneous cyst resolution was observed during expectant management with anticonvulsants. Two patients with multiple lesions were referred to us for further management but were free of active infection. Recent studies show that neurocysticercosis may often be diagnosed based upon the clinical, epidemiological and radiological features. Spontaneous cyst resolution is to be expected in this condition and suspected patients should be carefully observed and surgery avoided. We believe that this disease presents more commonly than has been appreciated in the UK and propose a protocol for management.

The Charing Cross Hospital experience with temozolomide in patients with gliomas.

Temozolomide, a new oral cytotoxic agent, was given to 75 patients with malignant gliomas. The schedule used was for the first course 150 mg/m2 per day for 5 days (i.e. total dose 750 mg/m2), escalating, if no significant myelosuppression was noted on day 22, to 200 mg/m2 per day for 5 days (i.e. total dose 1000 mg/m2) for subsequent courses at 4-week intervals. There were 27 patients with primary disease treated with two courses of temozolomide prior to their radiotherapy and 8 (30%) fulfilled the criteria for an objective response. There were 48 patients whose disease recurred after their initial surgery and radiotherapy and 12 (25%) fulfilled the criteria for an objective response. This gave an overall objective response rate of 20 (27%) out of 75 patients. Temozolomide was generally well tolerated, with little subjective toxicity and predictable myelosuppression. However, the responses induced with this schedule were of short duration and had relatively little impact on overall survival. In conclusion, temozolomide given in this schedule has activity against high grade glioma. However, studies evaluating chemotherapy in primary brain tumours should include a quality-of-life/performance status evaluation in addition to CT or MRI scanning assessment.

Temozolomide: a new oral cytotoxic chemotherapeutic agent with promising activity against primary brain tumours.

Temozolomide, a new oral cytotoxic agent, has been given to 28 patients with primary brain tumours. Treatment was given at a dose of 150 mg/m2/day for 5 days (i.e. total dose 750 mg/m2) escalating, if no significant myelosuppression was noted on day 22, to 200 mg/m2/day for 5 days (i.e. total dose 1000 mg/m2) for subsequent courses at 4 week intervals. A major improvement in computer tomography (CT) scan was noted in 5/10 patients with astrocytomas recurrent after radiotherapy, with a major clinical improvement but minor improvement on CT scan in one further patient. Reduction in the size of the CT lesion was also observed in 4/7 patients with newly diagnosed high grade astrocytomas given 2-3 courses of temozolomide prior to irradiation. 1 patient with recurrent medulloblastoma had a clinical response in bone metastases. Temozolomide was well tolerated with little subjective toxicity and usually predictable myelosuppression and is a promising new drug in the treatment of primary brain tumours.

The clinical significance of elevated CSF and plasma histamine in cerebral aneurysm surgery utilizing cardiopulmonary bypass with total circulatory arrest.

Recently there has been a renewed interest in the neurosurgical treatment of large cerebral aneurysms and AV malformations utilising cardiopulmonary bypass (CPB) and total circulatory arrest (TCA). However, the differing tolerance limits of coagulation and bleeding, pH control and fluid constraint are difficult to reconcile. Although clinical assessment, electro encephalogram (EEG) and intracranial pressure-monitoring assist in identification of cerebral damage, CPB and TCA inflict their own penalties with resultant uncertainty in post-operative neurological evaluation, and producing difficulties in interpretation and management. Additionally, an unanswered question is, to what extent the known cardiac and cerebral effects of circulating histamine might influence the post-circulatory arrest recovery in these patients, and whether this would further compromise the neurological result. We report our experience of 9 such cases who underwent this procedure, and were able to achieve a satisfactory neurological result in 7 patients with differing lesions. During the operation both CSF (from the open cranium) and blood (from the right internal jugular vein) were sampled at intervals for subsequent plasma histamine estimation. Despite markedly elevated histamine levels during CPB and TCA, this was not associated with an unfavourable neurological outcome. These early findings have given us encouragement to the useful role of CPB and TCA in these complex neurosurgical presentations, and raise interesting questions about the clinical importance of histamine-evoked cerebral ischaemia that has been demonstrated in experimental models.

Computer tomographic features of giant intracranial aneurysms.

Five cases of giant intracranial aneurysm are reported, all of which presented as intracranial mass lesions. All five aneurysms were visualised by CT scanning as well as angiography. Their CT scan appearances may be sufficiently characteristic to be distinguished from other mass lesions. The poor prognosis when untreated is emphasised, and the results of treatment by carotid ligation discussed.