bluuebunny/crossref_metadata_2025 huggingface dataset:
Effects of steroids and nonsteroid anti-inflammatory agents on vascular permeability in a rat glioma model
Authors: Reichman Howard R. , Farrell Catherine L. , Del Maestro Rolando F.
Published: May 2009

✓ Cerebral edema produced by brain tumors is clinically and experimentally reduced by steroid therapy. Nonsteroid anti-inflammatory drugs (NSAID's) which have been used to treat non-neural inflammation and swelling have not been evaluated for their ability to affect edema produced by brain tumors. The authors have used the rat C6 glioma spheroid implantation model to compare the effects of two steroids (dexamethasone and methylprednisolone) and two NSAID's (ibuprofen and indomethacin) on protein extravasation caused by intracranial gliomas. Evans blue dye was used as a marker for serum albumin extravasation. The concentration of Evans blue dye was measured in the tumor and peritumoral and contralateral brain tissue 1 hour after intravenous injection.

Extravasation of Evans blue dye within the tumor was decreased in all treatment groups when compared to placebo-injected control animals. The differences between the control specimens and those treated with dexamethasone, methylprednisolone, and indomethacin were highly significant (p < 0.005). The Evans blue staining was also decreased in the peritumoral and contralateral brain. These results indicate that NSAID's compare favorably with steroids in diminishing tumor-induced protein extravasation. It is suggested that NSAID's may prove to be beneficial in clinical instances used either in conjunction with steroid therapy or alone when steroids are contraindicated.
Aneurysm of the ICA petrous segment treated by balloon entrapment after EC-IC bypass
Authors: McGrail Kevin M. , Heros Roberto C. , Debrun Gerard , Beyerl Brian D.
Published: May 2009

✓ A 44-year-old man experienced the sudden onset of horizontal diplopia and hemifacial numbness. Arteriography demonstrated a left intrapetrous carotid artery aneurysm. The patient was successfully treated with a left superficial temporal artery to middle cerebral artery bypass followed by balloon entrapment of the aneurysm.

There have been at least 40 previously reported cases of aneurysms of the petrous portion of the carotid artery. These aneurysms can be mycotic, traumatic, or developmental in origin. They can present with massive otorrhagia or epistaxis from acute rupture or with decreased hearing and paresis of the fifth through eighth cranial nerves and, less frequently, of the ninth, 10th, and 12th cranial nerves caused by direct pressure. They can also produce pulsatile tinnitus, and sometimes they are discovered as a retrotympanic vascular mass during otological examination. The treatment of choice is carotid artery occlusion. Trapping of the aneurysm by detachable balloons eliminates immediately the risk of hemorrhage, offers the possibility of test occlusion of the internal carotid artery with the patient awake prior to permanent occlusion, and should also reduce the risk of thromboembolism. It should be preceded by a bypass procedure when preliminary evaluation indicates that the patient will not tolerate internal carotid artery occlusion.
Migration of a Heifetz aneurysm clip to the cauda equina causing lumbar radiculopathy
Authors: Oyesiku Nelson M. , Jones Robert K.
Published: May 2009

✓ A case is reported in which a Heifetz aneurysm clip, applied for the treatment of an aneurysm of the posterior inferior cerebellar artery, slipped and migrated into the cauda equina resulting in lumbar radiculopathy. Related reports are discussed briefly.
A Code of Ethics
Authors: Patterson Russel H.
Published: May 2009

✓ More than 50 years after the founding of the American Association of Neurological Surgeons as the Harvey Cushing Society, the delineation of a Code of Ethics constitutes a milestone for neurosurgeons. The reasons for developing the Code, its historical basis, and the continuing need to reinterpret any code in view of continuing changes in neurosurgical practice and delivery of health care are discussed.
Surgical management of giant sacral schwannomas
Authors: Abernathey Chad D. , Onofrio Burton M. , Scheithauer Bernd , Pairolero Peter C. , Shives Thomas C.
Published: May 2009

✓ Thirteen cases of giant sacral schwannomas with erosion of the anterior aspect of the sacrum and associated intrapelvic extension are reviewed. These tumors showed no sex predilection; the patients' mean age was 38.6 years at the time of diagnosis, and their symptoms predated the diagnosis by an average of 5.2 years. The most common symptoms were low-back pain and lower-extremity dysesthesiae. Plain roentgenograms, myelography, and computerized tomography constituted essential and complementary studies in the preoperative assessment. Choice of surgical approach (anterior transabdominal vs. posterior transsacral) was dependent upon the amount of sacral destruction, intrapelvic extension, and sacroiliac joint involvement. Microscopic examination revealed classic features of benign schwannoma in all but three cases, which were classified as cellular schwannomas. Patients who presented with pain and dysesthesiae reported immediate and complete relief of symptoms following surgery. In addition, all 13 patients were ambulatory and able to resume their routine daily activities postoperatively. At the last reported follow-up examination, which ranged from 5 months to 33 years and 3 months (mean 9 years) after surgery, two patients had died of unrelated causes, two reported return of preoperative symptoms, and the remainder were asymptomatic. This experience suggests that these histologically benign but neurologically devastating tumors should be aggressively resected with the intent of complete extirpation, and that this goal may be accomplished with minimal risk and an excellent prognosis.
Results of surgical treatment of neurocysticercosis in 69 cases
Authors: Colli Benedicto Oscar , Martelli Nelson , Assirati João Alberto , Machado Hélio Rubens , Forjaz Sylvio de Vergueiro
Published: May 2009

✓ The clinical course of 69 patients with neurocysticercosis who underwent surgery to control increased intracranial pressure (ICP) or cyst removal is analyzed. Increased ICP was caused by hydrocephalus in 63 patients, by cerebral edema in four, and by giant cysts in two. Skull x-ray films showed calcifications in 14% and signs of elevated ICP in 46%. Examination of cerebrospinal fluid (CSF) revealed pleocytosis with eosinophils in 52% of cases and a positive complement fixation test for cysticercosis in 66%. Ventriculography allowed localization of the CSF obstruction and ventricular cysts, and generally differentiated between an obstruction due to cysts and an inflammatory process. Computerized tomography showed cysts in the cerebral parenchyma and ventricular dilatation. Ventricular cysts were best seen when intraventricular metrizamide was used. Intracranial shunting and posterior fossa exploration were less effective in the treatment of hydrocephalus than was ventriculoatrial (VA) or ventriculoperitoneal (VP) shunting, although VA or VP shunting was associated with a high percentage of complications. Quality of survival was good in 87% of the cases in the first 3 postoperative months and in 93% of patients who survived 2 years after surgery. Fortyseven patients (68%) were readmitted one or more times for CSF shunt revision; 14 of them for shunt infection (meningitis). The early operative mortality rate was 1.8% for patients with VA or VP shunt placement and 5.3% for those with posterior fossa exploration. The authors conclude that placement of CSF shunts is indicated in the treatment of hydrocephalus, and cyst removal is indicated only when the cyst exhibits tumor-like behavior. Surgical exploration is also indicated when the diagnosis is uncertain.
Evaluation of cerebral AVM's using transcranial Doppler ultrasound
Authors: Lindegaard Karl-Fredrik , Grolimund Peter , Aaslid Rune , Nornes Helge
Published: May 2009

✓Blood flow velocities in basal cerebral arteries were recorded noninvasively in 28 patients with cerebral arteriovenous malformations (AVM's) and were correlated with the angiographic findings. In normal arteries remote from the AVM, flow velocities ranged from 44 to 94 cm/sec (median 65 cm/sec) with pulsatility indexes from 0.65 to 1.10 (median 0.87). This is consistent with findings in normal individuals. Arteries feeding the AVM's were identified by the high flow velocities (ranging from 75 to 237 cm/sec, median 124 cm/sec). The pulsatility index ranged from 0.22 to 0.74 (median 0.48). The difference of these results from findings in normal remote arteries was highly significant (p < 0.001). Hyperventilation tests illustrated the hemodynamic difference between an AVM and normal cerebrovascular beds.

Flow velocity measurements permitted noninvasive diagnosis of AVM's in 26 of the 28 patients. Furthermore, the identification of individual feeding arteries permitted good definition of the anatomical localization of individual AVM's. Flow velocity measurements combined with computerized tomography scans are useful in the diagnosis of AVM's. With the feeding artery's configuration identified on angiography, flow velocity measurements permit a new insight into the “hemodynamic dimension” of an AVM and its possible effects on adjacent normal brain-tissue perfusion in the individual patient.
Enolase isoenzymes in human gliomas
Authors: van den Doel Ernst M. H. , Rijksen Gert , Roholl Paul J. M. , van Veelen Cees W. M. , Staal Gerard E. J.
Published: May 2009

✓ Gamma-enolase (one of the three possible subunits of the dimeric enzyme enolase (EC 4.2.1.11)) has been reported as a marker for human neurons. Studies investigating the presence of γ-enolase in human gliomas have given conflicting results, but a definite finding is important for further studies of the biology of these tumors and the possible use of γ-enolase as a marker for tumors originating in nervous tissue or for neuronal damage. Using electrophoresis of tumor tissue extracts as well as immunohistochemistry the authors have demonstrated the presence of γ-enolase in human gliomas. Analysis of the γ-enolase content in the plasma of patients with brain neoplasms further revealed that, although this enzyme may be present in the tumor itself, its concentration in blood is not a reliable marker for a tumor of the human central nervous system.
Experimental brain abscess development in the chronically immunosuppressed host
Authors: Obana William G. , Britt Richard H. , Placone Richard C. , Stuart Jeffrey S. , Enzmann Dieter R.
Published: May 2009

✓ The neuropathological progression of brain abscess formation was studied experimentally in paired immunosuppressed and control dogs. The immunosuppressed animals received azathioprine and prednisone beginning 7 days prior to intracerebral inoculation with alpha streptococcus. Histological findings were correlated with computerized tomography (CT) brain scans. The evolution of brain abscess in the immunosuppressed animals could be divided into three stages based on histological evaluation: cerebritis stage (1 to 11 days), early-capsule stage (12 to 17 days), and late-capsule stage (18 days and later). There was a significant delay in the evolution of alpha streptococcus brain abscess compared to the authors' previous studies. Histologically, abscesses in immunosuppressed dogs were characterized by a decrease and delay in collagen formation, a reduction in polymorphonuclear leukocytes and macrophages, longer persistence of bacterial organisms, and an increase in gliosis. During the cerebritis stage, abscesses in control animals were consistently larger and more edematous than those in immunosuppressed animals and reached their maximum size by Day 8, whereas abscesses in immunocompromised animals reached their maximum size around Day 12. In the late-capsule stage, abscesses in immunosuppressed animals remained larger than those of control animals and continued to show signs of delayed development. This was evidenced by diffusion of contrast medium into the lucent center of ring-enhancing lesions on delayed CT scans. The results suggest that the decreased inflammatory response and edema formation in the immunosuppressed host resulted in less initial mass effect from brain abscess, but that the eventual size and area of the abscess may have become larger due to the less effective host response.
Extensive dural arteriovenous malformation
Authors: Al-Mefty Ossama , Jinkins John R. , Fox John L.
Published: May 2009

✓ A child with an extensive dural arteriovenous malformation (AVM) of the sigmoid sinus and bilateral occlusion of the transverse sinus is reported. His intracranial venous flow had become rerouted through the right cavernous sinus and then into the right ophthalmic veins. The AVM was associated with severe hydrocephalus and a progressive devastating neurological deficit. The hemodynamic and intracranial pressure changes as well as the mechanism of sinus thrombosis are discussed. The role of aggressive surgical treatment is emphasized.
Risks of surgery for unruptured intracranial aneurysms
Authors: Heiskanen Olli
Published: May 2009

✓ A series is presented of 43 patients with multiple aneurysms and subarachnoid hemorrhage in whom a second operation was necessary in order to clip all the aneurysms. There was one surgical death due to coronary thrombosis and infarction which occurred 3 weeks after surgery, for a surgical mortality rate of 2.3%. One patient developed a permanent neurological deficit (hemiparesis and dysphasia). Thus, the surgical risks are smaller than the natural risk of bleeding and death from hemorrhage. Patients with any other serious illness increasing the surgical risk should not be subjected to an operation for an unruptured aneurysm; a second operation is indicated in all low-risk patients with multiple aneurysms or with incidentally identified aneurysms.
Study of the posterior circulation in moyamoya disease
Authors: Miyamoto Susumu , Kikuchi Haruhiko , Karasawa Jun , Nagata Izumi , Ihara Ikuo , Yamagata Sen
Published: May 2009

✓ The involvement of the posterior circulation in moyamoya disease was studied in 178 patients. Forty-three had several types of disturbance such as visual field defect, decreased visual acuity, episodes of blindness, and scintillating scotomata. Most of these symptoms were attributed to occlusive lesions in the posterior circulation. Visual disturbances were seen more often in patients with a juvenile onset than in cases of adult onset.

Superficial temporal artery (STA) to middle cerebral artery (MCA) anastomosis and encephalomyosynangiosis (EMS) improved the cerebral perfusion both in the anterior and posterior circulation by redistribution of blood. In most cases, the visual symptoms subsided or were stabilized after STA-MCA anastomosis and EMS. These surgical procedures did not, however, lead to direct revascularization in cases of ischemia in the visual cortex. In five patients with impending blindness, transplantation of the omentum to the occipital lobe led to improved vision.
DREZ lesions for relief of pain related to spinal cord injury
Authors: Friedman Allan H. , Nashold Blaine S.
Published: May 2009

✓ Fifty-six patients with intractable pain following a spinal cord injury were treated with dorsal root entry zone (DREZ) lesions. After a follow-up period ranging from 6 months to 6 years, 50% of patients had good pain relief. Certain pain syndromes tended to respond better to DREZ lesions than did others. Patients with pain extending caudally from the level of the injury and patients with unilateral pain were most likely to obtain pain relief from the procedure; diffuse pain and predominant sacral pain did not respond as well.
Chemotherapy with cisplatin for AFP-secreting germ-cell tumors of the central nervous system
Authors: Kida Yoshihisa , Kobayashi Tatsuya , Yoshida Jun , Kato Kyouzou , Kageyama Naoki
Published: May 2009

✓ Therapeutic results in 17 cases of alpha-fetoprotein (AFP)-secreting tumors of the central nervous system are reported. Twelve of the patients were male and five female. The patients' ages ranged from 5 years to 25 years (mean 13.6 years). The tumors originated in the pineal region in 10 cases, in the suprasellar region in four cases, and in both regions in one case; of the other two tumors, one originated in the basal ganglia and one in the sacrococcygeal region. Extraneural metastases or subarachnoid dissemination occurred in seven cases. Increased AFP titer in the serum or cerebrospinal fluid was verified in 13 cases. The patients were divided into two groups: those treated before (Group A) and those treated after (Group B) the introduction in 1980 of cisplatin as a chemotherapeutic agent. All seven Group A patients died, even after extensive therapy consisting of surgery, radiotherapy, and chemotherapy (ACNU or adriamycin) in some of the cases. The mean survival time following diagnosis for Group A was 23.7 months. Six of the 10 Group B patients died an average of 25.8 months after diagnosis; however, the other four were still alive and well an average of 25.3 months after diagnosis. The tumors responded well to chemotherapy consisting of cisplatin either alone or combined with bleomycin and vinblastine. The initial response rate to treatment in Group B was 100% and five cases had a complete remission, verified by computerized tomography or the serum AFP level. Once the tumor recurred, the response to cisplatin was markedly decreased. It is suggested that an effective therapy must still be sought for recurrent tumors.
Detection of human glioma-associated antigen by rat monoclonal antibody raised against syngeneic rat glioma cells
Authors: Saya Hideyuki , Masuko Takashi , Kokunai Takashi , Yagita Hideo , Ijichi Akihiro , Taomoto Katsushi , Tamaki Norihiko , Matsumoto Satoshi , Hashimoto Yoshiyuki
Published: May 2009

✓ A monoclonal antibody termed “FR77” was obtained from a hybridoma clone established by fusion between P3x63Ag8.653 mouse myeloma cells and spleen cells of a Fischer F344 rat hyperimmune to syngeneic 9L/R3 glioma cells. Immunoperoxidase staining of various cultured cells showed that FR77 was reactive to both rat and human glioma cells, but was not reactive with other nonglioma cells. Immunohistochemical examination of paraffin-embedded or cryostat-frozen sections of various human tissues revealed that FR77 was strongly reactive with glioblastoma, grade III astrocytoma, and craniopharyngioma; partially reactive with intracerebral primitive neuroectodermal tumor, pineoblastoma, and desmoplastic medulloblastoma; and weakly reactive with low-grade astrocytoma. It was not reactive with other types of brain tumors and normal human tissues tested. The FR77-defined antigen was observed to be predominantly localized in the cytoplasm of antigen-bearing cells as suggested by the immunostaining pattern, but part of it was also expressed on the cell surface of glioma cells as demonstrated by a complement-mediated cytotoxic test. Fractionation of the antigenic component and periodic acid treatment of tumor tissue bearing the FR77-defined antigen indicated that the antigen is of a neutral glycolipid nature and that the antigenic determinant to FR77 is present on its sugar portion.
Neuronal responses in rostral trigeminal brain-stem nuclei of macaque monkeys after chronic trigeminal tractotomy
Authors: Young Ronald F. , Perryman Kent M.
Published: May 2009

✓ Unilateral trigeminal tractotomy was carried out at the level of the obex, just rostral to the subnucleus caudalis, in five young adult Macaca fascicularis monkeys. The animals had been trained previously to perform a behavioral shock avoidance task in response to electrical stimulation of dental pulp and facial skin. Tractotomy produced an elevation in the stimulus strength which elicited escape behavior when facial skin was stimulated but not when the tooth pulp was stimulated. Unit activity, evoked by electrical stimulation of the tooth pulp and facial skin as well as innocuous and noxious mechanical stimulation of orofacial regions, was recorded from neurons in the trigeminal main sensory nucleus and the subnuclei oralis and interpolaris of the spinal nucleus 8 to 12 weeks after tractotomy. Primary afferent input to these nuclei is unaffected by the tractotomy which is located more caudally. The tractotomy interrupts primary afferent input into the trigeminal nucleus caudalis and also intranuclear connections between caudalis and the more rostral nuclei. Forty-one units contralateral and 47 ipsilateral to the tractotomy were studied. Thirty-six of the units responded only to low-threshold mechanical or electrical stimulation of orofacial zones, 46 were responsive to innocuous mechanical and electrical stimulation of orofacial zones and also to electrical stimulation of the dental pulp. Six units responded only to dental pulp stimulation. No statistically significant differences between the populations of neurons ipsilateral and contralateral to the tractotomies were found relating to the size or location of the peripheral receptive fields, latencies, thresholds, mean firing densities, or responsiveness to the various forms of stimulation. The behavioral results suggest that trigeminal relay neurons rostral to the obex are able to signal dental pain sensation, and the physiological studies confirm that the firing of such neurons is unaffected by tractotomy. The physiological studies demonstrate that the firing patterns of relay neurons activated by natural and electrical cutaneous facial stimuli and which are located in trigeminal brain-stem nuclei rostral to the obex are also not affected by tractotomy. The cutaneous facial analgesia observed after tractotomy thus appears to be due to deafferentation of relay neurons in trigeminal nucleus caudalis rather than to alterations in coding patterns in rostrally located trigeminal neurons due to interruption of the intratrigeminal pathway between the caudal and rostral nuclear groups.
Surgical anatomy of the arteries of the posterior fossa
Authors: Shrontz Carl , Dujovny Manuel , Ausman James I. , Diaz Fernando G. , Pearce Jeffrey E. , Berman S. Kim , Hirsch Ellyn , Mirchandani Haresh G.
Published: May 2009

✓ The development of revascularization for vertebrobasilar ischemic events has created a need to identify the best sites at which to perform bypass procedures. Since the occlusive process may selectively affect various levels of the vertebrobasilar tree, sites in different vessels must be used to reestablish flow distal to the area of occlusion. Twenty-seven unfixed human brains were obtained 4 to 8 hours post mortem, and the vertebrobasilar system was injected with polyester resin. Under a surgical microscope the outer diameter, length, and site of origin of major branches were recorded for the following arteries: vertebral, basilar, posterior inferior cerebellar (PICA), anterior inferior cerebellar (AICA), superior cerebellar (SCA), and posterior cerebral (PCA).

The ideal sites for an anastomosis were identified as the pretonsillar segment of the PICA, the second portion of the AICA, the perimesencephalic segment of the SCA, and the perimesencephalic part of the PCA. Based on the anatomical observations reported here, these were the best sites because of their outer diameter, degree of mobility, least number of branches, and frequency of occurrence. Use of two of these arteries, however, may pose potential problems: although the PCA has an ideal outer diameter, it also has numerous branches to the brain stem in its most accessible site in the perimesencephalic area; and the PICA is not consistently present, being found in only 75% of the 27 specimens studied.
Ultrasound-guided stereotaxic biopsy using a new apparatus
Authors: Berger Mitchel S.
Published: May 2009

✓ A skull-mounted apparatus is described for use with ultrasound probes 16 mm in diameter (5.0-MHz probes for near-field and 7.5-MHz probes for far-field lesions). The system permits ultrasound-guided stereotaxic biopsy of intracranial lesions through a burr hole in awake or anesthetized patients. This apparatus has been used in 19 patients for biopsy of central nervous system lesions 1.5 to 5 cm in diameter and for drainage of abscess cavities and cysts. The time required to obtain a tissue sample after incision of the skin ranged from 25 to 40 minutes. The only complication was a delayed hemorrhage in a patient with acquired immunodeficiency syndrome. The advantages of this method over those guided by computerized tomography (CT) include less time required for the entire procedure, immediate confirmation of the biopsied target by imaging the echogenic needle track, assessment of cyst or abscess drainage, and detection of hemorrhage within minutes after biopsy. The apparatus may be especially useful in pediatric patients because it obviates the need for general anesthesia during transport to and from the CT scanner. This ultrasound-guided system does not require a craniotomy, craniectomy, or two separate burr holes.
Brain abscess aspiration in nursery with ultrasound guidance
Authors: Nagle Richard C. , Taekman Michael S. , Shallat Ronald F. , Cohen Ronald A.
Published: May 2009

✓ The authors report the case of a 1000-gm neonate who developed a frontal brain abscess due to a Serratia marcescens infection. The relationship of the mass to the neighboring ventricle and to the coronal suture was determined by computerized tomography. The mass was then successfully aspirated in the intensive care nursery with ultrasound guidance. A more prolonged operative procedure was avoided.
Traumatic infarction of the spinal cord in children
Authors: Choi Joong-Uhn , Hoffman Harold J. , Hendrick E. Bruce , Humphreys Robin P. , Keith William S.
Published: May 2009

✓ Infarction of the spinal cord in childhood is rarely due to trauma. During a 15-year period (1971 to 1985), eight children were admitted to The Hospital for Sick Children, Toronto, with a diagnosis of traumatic infarction of the spinal cord. All of these patients had delayed onset of neurological signs varying between 2 hours and 4 days after their initial trauma. No bone abnormalities were seen on plain spine x-ray films. Myelography was carried out in seven of these children and found to be normal in all seven. Six patients who were paraplegic at the time of admission remained permanently paraplegic, but two with incomplete cord signs did show some improvement.
Prognostic significance of ventricular CSF lactic acidosis in severe head injury
Authors: DeSalles Antonio A. F. , Kontos Hermes A. , Becker Donald P. , Yang Mildred S. , Ward John D. , Moulton Richard , Gruemer Hanns D. , Lutz Harry , Maset Angelo L. , Jenkins Larry , Marmarou Anthony , Muizelaar Paul
Published: May 2009

✓ Brain-tissue acidosis inferred by cerebrospinal fluid (CSF) lactic acidosis is considered to play an important role in the clinical course of severe head injury. Ventricular CSF lactate concentration was studied in 19 patients during the first 5 days after severe head injury. All patients were intubated, paralyzed, and artificially ventilated so that PaCO2 was kept at 33.2 ± 5.0 mm Hg and PaO2 at 122 ± 18 mm Hg (mean ± standard deviation). The mean Glasgow Coma Scale score on admission was 5.73 ± 2.42. The first CSF sample was drawn within 18 hours after head injury. Over the first 4 days postinjury, patients with a poor outcome had significantly higher ventricular CSF lactate levels than did those with moderate disabilities or a good outcome. Patients showing favorable outcome had a significant decrease in ventricular CSF lactate levels 48 hours after injury. This decrease was not observed in patients with a poor outcome. Increased ventricular CSF lactate concentration was also reliably associated with increased intracranial pressure (ICP). Ventricular CSF lactate levels did not correlate with the magnitude of intraventricular bleeding. Arterial and jugular venous blood lactate levels, although high after head injury, were usually lower than the levels in the ventricular CSF and reached a normal range by the 3rd day following head trauma. At that time, the ventricular CSF lactate concentration was still above normal in patients with a poor outcome but had decreased to normal in patients with moderate disabilities or a good outcome. Ventricular CSF pH did not generally correlate with the ventricular CSF lactate concentration in patients under controlled ventilation; however, in a few patients close to death or with ventricular infection, a correlation was noted. Ventricular CSF lactate levels were not related to cerebral blood flow. In this study, profiles of ventricular CSF lactate concentration are defined in relation to the patients' clinical course and outcome. High ventricular CSF lactate concentration is present within 18 hours after severe head injury. Its decrease to normal in the following 48 hours is a reliable sign of clinical improvement; however, ventricular CSF lactate levels that are persistently high or that increase over time indicate the patient's deterioration. Serial assessment of ventricular CSF for acid-base status and metabolites in head-injured patients with a ventricular catheter already placed for ICP monitoring is useful in the evaluation of prognosis and clinical course.
CSF brain creatine kinase levels and lactic acidosis in severe head injury
Authors: Rabow Lennart , DeSalles Antonio A. F. , Becker Donald P. , Yang Mildred , Kontos Hermes A. , Ward John D. , Moulton Richard J. , Clifton Guy , Gruemer Hanns D. , Muizelaar J. Paul , Marmarou Anthony
Published: May 2009

✓ The posttraumatic creatine kinase-BB isoenzyme (CKBB) activity and lactate concentration in ventricular cerebrospinal fluid (CSF) have been studied in 29 patients with severe head injuries. The CKBB activity reaches its maximum a few hours after trauma, and has a monoexponential drop with a half-time of approximately 10 hours. Ventricular CSF lactate concentration continues to rise in patients with a poor outcome, and decreases only slowly and inconsistently in most of the other patients. Thus, increase of lactate in the ventricular CSF is not, like CKBB, a direct one-stage consequence of the trauma but is due to continuous production from a derangement of metabolism caused by the trauma. Since even higher ventricular CSF lactate levels can be survived when not caused by head injury, and since no significant pH changes were related to the ventricular CSF lactic acidosis in these artificially ventilated patients, it is concluded that ventricular CSF lactic acidosis is indicative of a severe, although not necessarily intractable, disturbance of brain function associated with intracellular lactate production and acidosis.
Fluid secretion in arachnoid cysts as a clue to cerebro-spinal fluid absorption at the arachnoid granulation
Authors: Go K. Gwan , Houthoff Hendrik-Jan , Hartsuiker Johannes , Blaauw Engbert H. , Havinga Piet
Published: May 2009

✓ The morphological similarity of the lining of arachnoid cysts to subdural neurothelium and the mesothelium of arachnoid granulations suggested that the latter tissues might be the origin of arachnoid cysts. Transport Na+-K+-adenosine triphosphatase was shown by enzyme ultracytochemistry to be an indication of secretory activity in the lining of arachnoid cysts and in the endothelial lining of arachnoid granulations. This secretory activity suggests the existence of a biochemical mechanism for cerebrospinal fluid absorption at these granulations separate from the mechanisms already demonstrated.
Management of obstructive hydrocephalus secondary to posterior fossa tumors by steroids and subcutaneous ventricular catheter reservoir
Authors: Schmid Urs D. , Seiler Rolf W.
Published: May 2009

✓ In 61 patients (38 adults and 23 children) with surgically treatable tumors of the posterior fossa and obstructive hydrocephalus the following treatment for hydrocephalus was employed: 1) a high dose of steroids was given after diagnosis; 2) a frontal ventricular catheter with a subcutaneous fluid reservoir (Rickham) was inserted within 2 to 5 days; 3) a temporary external ventricular drainage system was attached to the reservoir if, despite the steroids, intracranial pressure was over 30 cm H2O; and 4) tumor excision was performed within 5 days to reopen the cerebrospinal fluid (CSF) pathways. In view of the wide range of potential complications, it was decided not to use a shunt before craniotomy. A shunt was inserted only if the CSF pathways remained obstructed after tumor removal. With this regimen, 93% of all patients (100% of the adults and 83% of the children) were shunt-free after the operation, without fatal complications. The infection rate was 4.9%.

It was concluded that the severity of symptoms of raised intracranial pressure from hydrocephalus, the intraventricular pressure, and the size or location of the tumor prior to surgery do not have prognostic value as to which patients will require a shunt after surgery.
Development of multiple lesions during radiation therapy and chemotherapy in patients with gliomas
Authors: Choucair Ali K. , Levin Victor A. , Gutin Philip H. , Davis Richard L. , Silver Pamela , Edwards Michael S. B. , Wilson Charles B.
Published: May 2009

✓ To determine the percentage of patients who developed multiple central nervous system (CNS) gliomas during postoperative radiation therapy and chemotherapy, the authors reviewed the records of 1047 patients treated between December 2, 1976, and August 16, 1985, who had an original diagnosis of supratentorial glioblastoma multiforme or other anaplastic glioma. The occurrence of multiple lesions was verified by neurodiagnostic studies (computerized tomography or myelography) or by findings at operation or autopsy. Twelve patients (1.1%) who presented with multiple lesions were excluded from this analysis. There were 405 patients with glioblastoma multiforme; their median age was 46.5 years (range 22 to 70 years). Eighteen (5%) of these patients had multiple CNS lesions, five of which were in the spinal cord. The median time from diagnosis to detection of the second lesion in this group was 59.5 weeks (range 10 to 182 weeks). There were 630 patients with anaplastic glioma (which included mixed malignant glioma and highly anaplastic, gemistocytic, moderately anaplastic, and anaplastic astrocytomas); their median age was 30 years (range 2 to 62 years). Fifty-four (8.6%) of these patients had multiple lesions, 10 of which were in the spinal cord; only one case of extraneural metastasis was found. The median time from diagnosis to detection of the second lesion in this group was 101 weeks (range 14 to 459 weeks). These results show that more than 90% of CNS gliomas recur at the site of the original tumor. Considering the high frequency of intellectual dysfunction after whole-brain radiation therapy, the use of focal radiation fields appears to be the most judicious approach to the treatment of patients with gliomas.
Effect of difluoromethylornithine on the antiglioma therapeutic efficacy of intra-arterial BCNU
Authors: Cohen Alan R. , Pietronigro Dennis D. , Cravioto Humberto , Flamm Eugene S.
Published: May 2009

✓ In an attempt to improve glioma management, an animal model was developed to evaluate the therapeutic efficacy of intra-arterial 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU). Furthermore, the model was used to study the antitumor activity of D,L-alpha-difluoromethylornithine (DFMO), a polyamine-biosynthesis inhibitor, used both as a single agent and in combination with intra-arterial BCNU.

An N-methylnitrosourea-induced gliosarcoma (T9) was transplanted stereotaxically into the right caudate nucleus of male Fischer 344 rats. Animals receiving a single low-dose (5 mg/kg) intracarotid injection of BCNU 9 days following tumor implantation had a 57% increase in life span compared with untreated control rats (p < 0.001). Intracarotid drug delivery was more effective than systemic (intraperitoneal) administration of the same dose of BCNU.

When given as a single agent, DFMO demonstrated dose-dependent effectiveness. As part of a combined regimen, DFMO enhanced the antitumor therapeutic activity of both systemic (intraperitoneal) and intra-arterial BCNU. Survival times of animals receiving combined DFMO and intra-arterial BCNU were almost double those of untreated controls, and were significantly better than survival times of animals receiving combined DFMO and intraperitoneal BCNU. These findings suggest methods to optimize current clinical chemotherapy for glioma.
Carrageenan-induced brain inflammation
Authors: Gamache Daniel A. , Povlishock John T. , Ellis Earl F.
Published: May 2009

✓ Administration of the mucopolysaccharide, carrageenan (CAR), into the hind paw of the rat or mouse induces a local inflammation characterized by increased arachidonic acid metabolism, increased vascular permeability, edema, and neutrophil extravasation. Carrageenan-induced hind-paw inflammation is inhibited by prostaglandin synthesis inhibitors, and this assay predicts the clinical success of anti-inflammatory agents in reducing peripheral inflammation. The purpose of this study was to determine if intraventricular injection of CAR would induce brain inflammation similar to that evoked by CAR in peripheral tissues. The present study demonstrates that CAR injection into the ventricles of the mouse brain does in fact induce an inflammatory response very similar to that caused by injection of CAR into the peripheral tissues. The brain response to CAR was dose-dependent, with the maximum increase in cerebrovascular permeability to iodine-125-labeled human serum albumin and percent brain water occurring after injection of 50 µg CAR. As is seen in CAR-induced inflammation of the hind paw, the maximum increase in brain vascular permeability occurred 4 hours after CAR injection. Histological analysis of brains 4 hours after CAR administration showed global neutrophil extravasation into the subarachnoid space and evidence of focal neuronal swelling. Methotrexate-induced neutropenia, however, failed to diminish the permeability response to CAR. Gas chromatographic and mass spectrometric measurements of brain prostaglandins 4 hours after CAR injection revealed a significantly increased level of 6-keto-prostaglandin F1α. These results indicate that a significant increase in prostacyclin, the pro-inflammatory arachidonic acid metabolite, during CAR-induced brain inflammation is likely. These studies suggest that CAR-induced brain inflammation may be a useful model on which to test the efficacy of anti-inflammatory agents in the brain, as well as providing information concerning the mediators and mechanisms by which the brain may sustain inflammatory injury.
Progressive neurological deficits with benign intracerebral cysts
Authors: Nakasu Yoko , Handa Jyoji , Watanabe Kazuyoshi
Published: May 2009

✓ Two patients with benign intracerebral cysts are reported and a brief review of the literature is given. Although computerized tomography (CT) scanning is useful in detecting a variety of intracerebral cysts, the CT findings are not specific for any lesion. An exploratory operation with establishment of an adequate route of drainage and a histological examination of the cyst wall are mandatory in the management of patients with a progressive but benign lesion.
Intracerebral hematoma following evacuation of chronic subdural hematomas
Authors: d'Avella Domenico , De Blasi Francesco , Rotilio Antonino , Pensabene Vincenzo , Pandolfo Nicola
Published: May 2009

✓ Two cases of intracerebral hemorrhage occurring after evacuation of bilateral chronic subdural hematomas are reported. Possible pathogenic mechanisms included hemorrhage into previously undetected areas of contusion, damage to cerebral vasculature secondary to rapid perioperative parenchymal shift, and sudden increase in cerebral blood flow combined with focal disruption of autoregulation; of these, the latter mechanism seemed most likely to be responsible for the hematoma formation. The need for clinical awareness of this nearly uniformly devastating complication, as well as prompt use of computerized tomography scanning in assessing the postoperative course, are stressed.
Pathology of invasive pituitary tumors with special reference to functional classification
Authors: Scheithauer Bernd W. , Kovacs Kalman T. , Laws Edward R. , Randall Raymond V.
Published: May 2009

✓ Pituitary adenomas may remain intrasellar or infiltrate dura and bone. Invasive adenomas are not considered to be malignant; in biological behavior they are between non-infiltrative adenomas and pituitary carcinomas. The latter are defined as tumors with subarachnoid, brain, or systemic metastasis. Invasion may be defined radiologically, operatively, or histologically. On the basis of operatively assessed tumor size and gross invasion of dura and bone as well as immunocytochemical and ultrastructural analysis of 365 pituitary adenomas, the following data were obtained. There were 23 growth hormone (GH)-cell adenomas: 14% microadenomas and 86% macroadenomas; their overall frequency of invasion was 50%. There were 24 prolactin (PRL)-cell adenomas: 33% microadenomas and 67% macroadenomas, with an overall frequency of invasion of 52%. Mixed GH-cell and PRL-cell adenomas were found in 35 cases; 26% were microadenomas and 74% were macroadenomas, and the overall frequency of invasion was 31%. Sixty patients had adrenocorticotropic hormone (ACTH)-cell adenomas (Cushing's disease): 87% microadenomas and 13% macroadenomas; the overall frequency of invasion was 25% (in 8% of microadenomas and 62% of macroadenomas). Twenty patients had ACTH-cell adenomas (Nelson's syndrome): 30% microadenomas and 70% macroadenomas; the overall frequency of invasion in these cases was 50% (in 17% of microadenomas and 64% of macroadenomas). Silent ACTH-cell adenomas, 100% macroadenomas, were found in 11 patients, with an 82% frequency of invasion. There were 32 follicle-stimulating and luteinizing hormone adenomas, all macroadenomas, with a frequency of invasion of 21%. Four patients had thyroid-stimulating hormone adenomas, all macroadenomas, with a 75% frequency of invasion. Null-cell adenomas were found in 93 cases: 2% microadenomas and 98% macroadenomas, with a frequency of invasion of 42%. There were 63 plurihormonal adenomas (GH, PRL, glycoprotein): 25% microadenomas and 75% macroadenomas, with a 50% overall frequency of invasion.

Based on this study, and on their usual frequency of occurrence, the estimated rate of gross invasion by pituitary adenomas of all types is approximately 35%. It is concluded that immunocytochemical and ultrastructural characteristics of pituitary adenomas reflect the tendency of these tumors to infiltrate and hence may be of prognostic significance.
Diagnosis and management of pediatric brain-stem gliomas
Authors: Stroink Ann R. , Hoffman Harold J. , Hendrick E. Bruce , Humphreys Robin P.
Published: May 2009

✓ The authors reviewed the cases of 49 children, ranging in age from 9 months to 15 years, who were diagnosed by computerized tomography (CT) as having brain-stem glioma. Four distinct groups of brain-stem gliomas were identified based on CT scan characteristics: Group I included isodense contrast-enhancing tumors that were dorsally exophytic into the fourth ventricle; Group II(a) included hypodense nonenhancing intrinsic tumors of the brain stem; Group II(b) included intrinsic tumors of the brain stem with hyperdense exophytic components extending ventrally and laterally into the cerebellopontine and prepontine cisterns; Group III included intrinsic cystic tumors with contrast-enhancing capsules; and Group IV included focally intrinsic tumors of the brain stem that were isodense and enhanced brightly on administration of contrast medium.

The clinical presentation, efficacy of surgical intervention, pathology, and prognosis of these tumors were correlated within these groupings. Eleven patients had Group I tumors, all of which were surgically resected; 10 of the 11 lesions were proven to be low-grade gliomas. These patients had an excellent prognosis; 10 of the 11 survived, with a mean follow-up period of 4.5 years. There were 18 patients with Group II(a) tumors; although tumor biopsy was attempted on eight of these, pathological diagnosis at the time of surgery was made in only one case. These patients did poorly; the mean survival time was 6.2 months. The seven Group II(b) tumor patients demonstrated a similarly poor prognosis: all of them died within 23 months of diagnosis, with a mean survival time of 12 months. Only two of six patients undergoing biopsy had sufficient tissue for histological verification. Three of the four patients with Group III tumors died; their mean survival time was 11.5 months. Successful histological examination was carried out in all four cases. The nine Group IV tumor patients did reasonably well; seven of these patients remain alive, with a mean follow-up period of 2.3 years. Histological diagnosis was obtained in three of the seven patients who were explored in this group. This classification system has proven to be of value in determining prognosis and efficacy of surgical intervention.
Complications associated with the halo-vest
Authors: Glaser John A. , Whitehill Richard , Stamp Warren G. , Jane John A.
Published: May 2009

✓ The cases of all patients treated with halo-vests for cervical trauma at the University of Virginia since 1977 were analyzed retrospectively. A standardized chart and radiographic review protocol were used to identify complications associated with the use of the orthosis. Two hundred and forty-five patients satisfied the criteria for inclusion in the study. No patient developed or suffered progression of a neurological deficit while immobilized. Complications included: pneumonia causing death (one patient); loss of reduction or progression of the spinal deformity (23 patients); spinal instability following orthotic immobilization for 3 months (24 patients); pin-track infection (13 patients); migration of anteriorly placed iliac-strut grafts (two patients); cerebrospinal fluid leakage from a halo pinhole (one patient); and miscellaneous (seven patients).

The findings indicate several conclusions. 1) The halo-vest protects patients with cervical instability from neurological injury. 2) It does not absolutely immobilize the cervical spine nor does it prevent progressive deformity of malpositioned strut grafts. 3) Even after a 3-month orthotic treatment period, surgery may be required on ligamentous and osseous injuries to provide spinal stability. 4) Elderly kyphotic patients may require custom-made vests. 5) A small subset of patients exists for whom the confining nature of the halo-vest is intolerable for 3 months.
Dermoid tumors occurring at the site of previous myelomeningocele repair
Authors: Scott R. Michael , Wolpert Samuel M. , Bartoshesky Louis E. , Zimbler Seymour , Klauber George T.
Published: May 2009

✓ Four children with previously repaired myelomeningoceles presented toward the end of the first decade or early in the second decade of life with deteriorating lower-extremity and bladder function. Myelography and computerized tomography scanning demonstrated irregular filling defects at the area of the myelomeningocele repair, and surgical exploration disclosed dermoid tumors that were adherent to the placode and adjacent roots. Dermoid tumors should be considered in the differential diagnosis of neurological deterioration in children with a repaired myelomeningocele.