Analysis of risk factors influencing the development of severe dizziness in patients with vestibular schwannomas in the immediate postoperative phase.

OBJECTIVE: Dizziness, a common postoperative symptom in patients with vestibular schwannomas (VSs) has a negative effect on the course of recovery, particularly in patients with severe symptoms. Reports on incidence and possible risk factors contributing to these symptoms are inconsistent and sometimes even contradictory. In order to establish a profile of patients at risk of severe symptoms in the immediate postoperative phase we retrospectively analyzed data of patients with unilateral VSs focusing on the incidence of severe dizziness and nausea during the immediate postoperative period and up to 1 year after surgery. METHODS: In a retrospective study data of 104 consecutive patients with VSs were analyzed. All patients underwent microsurgical tumor resection via a lateral-suboccipital approach. Factors that were assumed to affect the development of severe dizziness, such as age, gender, tumor size, tumor side, and cranial nerve function, were analyzed by means of univariate and multivariate logistic regression analyses. A three step grading system was used to describe symptoms of patients included in this study: 0=no symptoms of dizziness, 1=slight dizziness including light-headedness or feeling of disequilibrium and 2=severe dizziness with nausea including imbalance or insecurity when walking, requiring antiemetic treatment. RESULTS: Data of 92 patients, 41 men and 51 women, were available for analyses. Mean age of treated patients was 53 years (range 17-81). There was no predilection of side (52.2% right/47.8% left). Before surgery 39 patients (42.4%) were symptom free (grade 0), 13 patients (14.1%) had slight symptoms (grade 1) and 40 patients (43.5%) suffered from severe symptoms (grade 2). Immediately after surgery two patients (2.2%) where symptom free (grade 0), 19 patients (20.7%) had slight symptoms (grade 1) and 71 patients (77.2%) suffered from severe symptoms (grade 2). All patients with grade 2 symptoms required antiemetic treatment ranging between 1 and 10 days (mean 4 days). Logistic regression analyses showed young age, large tumor size (T3/T4), female gender, and severe preoperative symptoms to be main factors increasing the odds for patients to develop severe symptoms postoperatively. CONCLUSION: Patients at risk to develop severe symptoms should receive antiemetic treatment even before surgery. If in doubt about the actual risk for a specific patient with a large tumor (T3 or T4) available data suggests that patients will benefit if antiemetic treatment is started early, even before surgery.

Reliability of atlas-derived coordinates in deep brain stimulation.

BACKGROUND: In deep brain stimulation the way to define and localize the optimal target for the individual patient is still under debate. The objective of our study was to investigate the reliability of atlas derived data by comparing them with direct targeting on MR images. METHOD: We investigated 28 STN targets in 14 volunteers. The stereotactic coordinates of the dorso-lateral subthalamic nucleus (STN), were determined in 5 different ways for both STNs of each individual volunteer: 1. directly, on axial T2WI spin echo slices, 2. directly, on coronal T2WI spin echo slices and after fusion of data sets: 3. indirectly, on an axial atlas plate, 4. indirectly, on a coronal atlas plate, 5. indirectly, 12 mm lateral, 3 mm posterior and 3 mm inferior to mid-AC-PC. FINDINGS: The differences between MRI derived targets on axial vs. coronal slices were not statistically significant. After detection of the atlas derived targets the resulting x-coordinates were found more lateral than after direct detection on both, axial and coronal T2-weighted images (p < 0.001). On axial images y-coordinates were located more anterior (p = 0.240) on atlas derived targets and more posterior when target localizations were compared on coronal slices (p < 0.001). z-Coordinates were more superior after atlas targeting compared to MRI targeting (p < 0.001). Differences up to 6.21 mm occurred. CONCLUSIONS: Despite the limitations concerning image distortions and slice thickness, direct target planning on MRI, regarding our results, is more reliable than targeting solely based on atlas derived data. Only MRI gives us detailed information about the individual configurations of central structures in every single patient. However, targets, which are not detectable on MRI like the nucleus ventralis intermedius have to be planned using stereotactic atlas information. In these cases intra-operative micro-electrode recording might help to better define the target region.

Image fusion of MR images and real-time ultrasonography: evaluation of fusion accuracy combining two commercial instruments, a neuronavigation system and a ultrasound system.

OBJECTIVE: The aim of our study was to evaluate MRI/Ultrasonography fusion accuracy depending on three ultrasonographic parameters. METHOD: An ultrasonography and MRI compatible model was created, consisting of a plastic box, which contained 3 objects. MRI scans were performed with 128 sagittal slices. The objects were segmented and 3D reconstructions were created. A special ultrasound adapter with 3 reflective markers was fixed to the ultrasound probe. Thus, the probe could be tracked by the navigation system (Vector Vision(2), BrainLab, Heimstetten, Germany) and the segmented shape of the 3D-objects obtained from the MR images were overlaid onto the ultrasound display (Elegra, Siemens, Erlangen, Germany). The dependency of fusion accuracy on different depth of ultrasound display, different distances between probe and objects and different angles between the axis of the ultrasound probe and the centre of the spheres was evaluated. 435 single measurements were performed. FINDINGS: Overall fusion accuracy was 1.08 mm+/-0.61 mm (mean +/- standard deviation) for spheres and 1.6 mm+/-1.1 mm for arrow heads. If the ultrasound probe was directed more tangentially to the surface of the spheres the fusion became increasingly inaccurate (P<0.05). Fusion accuracy decreased the more distant the US probe was held to the object (P<0.05). Different depth of ultrasound display had no significant effect on fusion accuracy. CONCLUSIONS: Highly accurate fusion of MR images and real-time ultrasonography could be achieved. However, careful interpretation of the fused data is necessary, when different angles and distances of the US probe to the object are concerned.

Registration accuracy and practicability of laser-directed surface matching.

The aim of our study was to evaluate the registration accuracy and practicability of a new laser registration technique in comparison to marker registration. From January to August 2001, 36 patients (23 male, 13 female) with brain lesions were operated with navigational guidance. Thirty-five patients were registered by paired-point registration. In 16 patients, a second registration was carried out using a special laser pointer for surface matching (z-touch trade mark, BrainLab, Heimstetten, Germany). Accuracy was evaluated by touching seven anatomic landmarks and a target fiducial with the nonsterile pointer. The distance from the virtual pointer tip to these points was determined on the monitor display (600% zoom). Laser registration is fully retrospective and allows registrations when no markers are applied. z-touch trade mark registration is more sophisticated and time-consuming than marker-based registration (registration time for z-touch trade mark = 7.4 +/- 3.7 min; for markers = 4.1 +/- 1.7 min; p < 0.005). Marker registration proved to be more accurate than z-touch trade mark registration with regard to localization of anatomical landmarks and target fiducials (precision with z-touch trade mark = 2.77 +/- 1.64 mm; with markers = 1.31 +/- 0.87 mm; p < 0.01). Although the registration error was increased and preparation time prolonged with the z-touch trade mark technique, it proved to be a valuable option, especially in children.

TRP4 (CCE1) protein is part of native calcium release-activated Ca2+-like channels in adrenal cells.

Mammalian TRP proteins have been implicated to function as ion channel subunits responsible for agonist-induced Ca(2+) entry. To date, TRP proteins have been extensively studied by heterologous expression giving rise to diverse channel properties and activation mechanisms including store-operated mechanisms. However, the molecular structure and the functional properties of native TRP channels still remain elusive. Here we analyze the properties of TRP4 (CCE1) channels in their native environment and characterize TRP expression patterns and store-operated calcium currents that are endogenous to bovine adrenal cells. We show by Northern blot analysis, immunoblots, and immunohistochemistry that TRP4 transcripts and TRP4 protein are present in the adrenal cortex but absent in the medulla. Correspondingly, bovine adrenal cortex cells express TRP4 abundantly. The only other TRP transcript found at considerable levels was TRP1, whereas TRP2, TRP3, TRP5(CCE2), and TRP6 were not detectable. Depletion of calcium stores with inositol 1,4,5-trisphosphate or thapsigargin activates store-operated ion channels in adrenal cells. These channels closely resemble calcium release-activated Ca(2+) (CRAC) channels. Expression of trp4(CCE1) cDNA in antisense orientation significantly reduces both, the endogenous CRAC-like currents and the amount of native TRP4 protein. These results demonstrate that TRP4 contributes essentially to the formation of native CRAC-like channels in adrenal cells.

Phenotype of a recombinant store-operated channel: highly selective permeation of Ca2+.

1. Genes related to trp (transient receptor potential) are proposed to encode store-operated channels. We examined the ionic permeation of recombinant channels formed by stable and transient expression of the TRP homologue bCCE1 in Chinese hamster ovary (CHO) cells (CHO(CCE1)) and rat basophilic leukaemia (RBL) cells, respectively. 2. Store-operated currents were activated in CHO(CCE1) cells by internal dialysis of IP3 under strong buffering of intracellular Ca2+. The action of IP3 was mimicked by thapsigargin but not by IP4. 3. With extracellular Ca2+, Na+ and Mg2+, the store-operated currents of CHO(CCE1) rectified inwardly in the presence of internal Cs+. Outward currents were not detected below +80 mV. Identical currents were recorded with external Ba2+ and also with no external Na+ and Mg2+. In the absence of external Mg2+, the inward currents showed an anomalous mole fraction behaviour between Ca2+ and Na+. Half-maximal inhibition of Na+ currents was observed with approximately 100 nM and full block with 2-5 microM external Ca2+. 4. In the parental CHO(-) cells, IP3 dialysis evoked inward currents that also displayed anomalous mole fraction behaviour between Ca2+ and Na+. However, half-maximal block of Na+ currents required 5 times higher Ca2+ concentrations in CHO(-) cells. Additionally, the density of Ca2+ and Na+ currents at -80 mV was 5 and 2 times larger in CHO(CCE1) cells, respectively. 5. In RBL cells, dialysis of IP3 evoked store-operated currents that showed 1.4-fold larger densities at -80 mV in cells expressing bCCE1. 6. The enhanced density of store-operated currents in CHO(CCE1) cells and in bCCE1-transfected RBL cells probably reflects the phenotype of CCE1. These results suggest a highly selective permeation of Ca2+ through recombinant channels formed by CCE1 either alone or in combination with endogenous channel proteins.