[Hemicraniectomy in malignant mid-cerebral infarction. Further trials needed before its acceptance in clinical practice]. / Hemikraniektomi vid malign media-infarkt. Flera prövningar före allmän acceptans i klinisk praxis.

In cases of completed middle cerebral artery territory stroke, prognosis is very poor and the clinical course is characterised by a rapid decline in consciousness and signs of herniation 2-4 days after the onset of symptoms due to a space-occupying mass. Failure of conservative therapy is the rule, and herniation is the usual cause of death, occurring in almost 80 per cent of cases. Recently published results have suggested that hemicraniectomy may improve survival in patients with massive hemisphericstroke, decreasing mortality to less than 35 per cent. The article presents what is probably the first case to be reported in Sweden, where hemicraniectomy was performed on a 45-year-old woman with right hemispheric completed middle cerebral artery infarction.

Microvascular decompression for trigeminal neuralgia: no relation between sensory disturbance and outcome.

Trigeminal nerve microvascular decompression (MVD) relieves the pain in a great majority of patients. However, there has been a debate regarding whether the pain-relieving effect is due to the decompression itself or a surgical trauma to the nerve. In 37 consecutive patients, the facial sensibility was quantitatively assessed and the function of other cranial nerves was investigated before and after MVD. The patients were followed for 1-5 years (mean 3.4 years) to assess the surgical outcome. Twelve patients (32%) experienced a mild postoperative sensory deficit assessed by clinical examination. When measured quantitatively with electrical stimulation, sensory thresholds for perception and pain were elevated more than 25% in 16 of the patients (43%). All together 19 patients (51%) did not have any sensory deficit as assessed by either of the two methods used. No severe postoperative cranial nerve dysfunctions were noted in this series. Three patients (8%) had a recurrence of pain at 7-9 months postoperatively. Two of those patients had a moderate elevation of measured sensory thresholds. All 19 patients with no cranial nerve deficits after MVD experienced an excellent pain relief. It seems that trauma to the trigeminal nerve is not a prerequisite for obtaining pain relief after MVD for trigeminal neuralgia.

Chromosome 17 abnormalities and lack of TP53 mutations in paediatric central nervous system tumours.

Central nervous system (CNS) tumours are the most common solid tumours in children. Cytogenetic and molecular genetic studies of these neoplasms have previously shown abnormalities of chromosome 17, implicating genes on this autosome in tumorigenesis. To identify mutations in the TP53 tumour suppressor gene (17p13.1), we have sequenced the five highly conserved regions of this gene in 29 mixed paediatric CNS tumors. No mutations were detected by this analysis. In order to identify other candidate disease loci on chromosome 17, we have carried out a detailed deletion mapping analysis using 16 polymorphic DNA markers on 19 of the above tumours and an additional four cases. Abnormalities of chromosome 17 occurred in nine cases (39%), six of which were primitive neuroectodermal tumour (PNET)-medulloblastomas. These findings suggest that it is unlikely that the TP53 gene is directly involved in the development of common paediatric brain tumours. This is in contrast to findings from adult brain and other tumour types. Moreover, the frequency of chromosome 17 aberrations, especially in PNET-medulloblastomas, suggests that other genes on this chromosome contribute to tumourigenesis.

Does a routine operation for intracranial aneurysm incur brain damage?

A biochemical marker of brain cell damage, the BB-isozyme of the intracellular enzyme Creatine Kinase (CK), was used to evaluate any possible injury to the brain, caused by an operation for a ruptured intracranial aneurysm (SAH). CSF-CK BB was assessed before and at intervals after operation in a series of 60 patients, aged 29-71 (mean 51 years) operated on for intracranial aneurysms, all but one after SAH. The m/f ratio was 18/42. 35 of the 60 patients were operated on acutely, i.e. within 72 hours after the SAH. CK BB was determined as CKB-activity after immunological inactivation of CKM. Normally there should be almost no detectable enzyme activity in the CSF. The pre-operative CK BB-activity was 0.01+ -0.01 mikrokatal in the patients in Hunt & Hess grade I who were operated on > 7 days after their SAH, and 0.05+ -0.04 in those operated on acutely, probably still reflecting the effects of the SAH on the brain. The mean per-operative CK BB increase was 0.11+ -0.17 for patients who had an uneventful postoperative course, compared to 0.39+ -0.49 for those showing some degree of immediate postoperative deterioration. This difference is significant at the 1% level. 52 of the 60 patients showed a rise of CK BB after operation. The mean increase for those patients operated upon in a good state and without any complication or postoperative deterioration was 0.02+ -0.03 mikrokatal, which could therefore be considered as a "normal" or acceptable elevation.(ABSTRACT TRUNCATED AT 250 WORDS)

Expression of estramustine-binding protein in ependymomas and in human and developing rat ependymal cells.

The mainstays of primary treatment of ependymoma are aggressive surgery followed by radiotherapy. Although spreading occasionally occurs in the cerebrospinal pathways, chemotherapy is still not established and no ultimate drug has so far been found. Estramustine-phosphate (EMP), with a demonstrated effect on astrocytoma in vitro, has been shown to penetrate the blood-tumor barrier and to accumulate in human brain tumor tissue including ependymoma. It has been proposed that the cytotoxic effect of EMP depends on the presence of a binding protein, estramustine-binding protein (EMBP). In the present paper we have, for the first time, immunohistochemically demonstrated an EMBP-like protein in a series of ependymomas. Immunoreactivity was found within the cytoplasm of the tumor cells with a tendency to increase with increasing malignancy of the tumor. In addition, the occurrence of EMBP-like protein was demonstrated in human ependymal cells. In the rat brain, a weak immunoreactivity was detected in early fetal neuroepithelial cells while the staining intensity was increased in mature ependymal cells in late fetal, neonatal, and adult rat. Thus; immunoreactivity for an EMBP-like protein was demonstrated in ependymoma tissue, normal human ependyma and in the developing rat ependymal cells.

Loss of genetic information in central nervous system tumors common to children and young adults.

The clonal loss of genetic information as revealed by the comparison of normal and tumor DNA restriction fragment length alleles has permitted the determination of the genomic positions of cancer-recessive mutations. Here we have applied this approach to the analysis of 19 central nervous system tumors that constitute four histologic groups and occur most frequently in children and young adults. The detectable loss of genetic information from cases of medulloblastoma (11 examined) indicates that among such tumors, loss occurs most frequently from the short arm of chromosome 17. For the ependymomas examined (four cases), chromosome 22 was the preferred site for detectable loss. Analysis of pilocytic astrocytomas of the cerebellum (three cases) failed to reveal genetic alterations of any type among such tumors, a finding unique to this histologic group. The single choroid plexus papilloma examined demonstrated loss of genetic information from chromosome 3. Among the 19 tumors, multiple cases of loss were observed from chromosomes 10, 11, 13, and 22, and from the short arm of chromosome 17. Therefore, with regard to the chromosomal locations of implied tumor suppressor genes, these results are consistent with those described for intracranial tumors occurring more commonly in adults of middle to advanced age.

Microvascular decompression for trigeminal neuralgia.

An analysis of 57 patients with trigeminal neuralgia (TN) treated with microvascular decompression (MVD) is presented. Mean follow-up time was 3.1 years. Vascular compression of the trigeminal nerve root was noted in 54 cases. In the remaining 3 patients, adhesions were observed in two, whereas no obvious cause was found in one case. Among the patients with vascular compression, 43 (80%) became painfree immediately after surgery, and have remained so during the observation period. There was an indisputable relationship between the degree of observed vascular compression of the nerve and long-term complete pain relief. There was no mortality in association with the surgery. Major morbidity was seen in 3.6%, and partial facial sensory loss was seen in seven patients (12%). The implications of these findings are discussed.

Indirect injury to cranial nerves after surgery with Cavitron ultrasonic surgical aspirator (CUSA). Case report.

The Cavitron ultrasonic surgical aspirator (CUSA) was used in a patient with an acoustic nerve tumour. After surgery she presented unilateral palsies of several cranial nerves. The nerve injuries were most likely induced by ultrasonic energy transmitted from the CUSA via the petrous bone. We suggest that when the CUSA is used in such operations care should be taken to avoid contact between the vibrating probe of the CUSA and the petrous bone.

Intracranially recorded compound action potentials from the human trigeminal nerve.

Potentials from the sensory root of the trigeminal nerve in the cerebello-pontine angle, evoked by electrical stimulation of the different trigeminal divisions, were recorded during neurosurgical operations. Two components of the compound action potential could be distinguished: one early with large amplitude and one late with small amplitude. It is concluded that the two components represent activity in A alpha and A delta fibers respectively.

Topical application of penicillin into hippocampal in vitro slices: A methodological study using benzyl (14C) penicillin.

A gas pressure system is employed for topical application of pico/nanolitre volumes of 9 mmol/l benzyl (14C) penicillin into guinea-pig in vitro transverse hippocampal slices. Control of pressure pulse parameters enables ejectates, computed after liquid scintillation, from 10 micrometer, 5 micrometer and 2 micrometer pipettes with high reliability of ejection. A detailed study was done on the ejection performance of 5 micrometer and 2 micrometer pipettes. It shows that for the 5 micrometer tips, with the chosen ejection parameters, feeding pressure = 0.5 MPa, feeding pulse duration 50 ms, a 99% ejection incidence was obtained (n = 200). The mean volumes ejected were 0.12 and 0.5 nl (n = 50) for one and four pulses delivered respectively. The corresponding ejectate means obtained from five 2 micrometer pipettes given a feeding pressure of 1.5 MPa, and a feeding pulse duration of 70 ms, were 0.04 and 0.13 nl. Statistical evaluation of the individual pipette ejection performances gave characteristic regression slopes within each pipette group. A comparison between visually controlled injection into oil and injection into slice, showed a close correspondence. The applicability of the ejection method is discussed in relation to functional studies on the conversion of single neurones into "epileptic" ones.