Posterior Subthalamic Area Deep Brain Stimulation for Treatment of Refractory Holmes Tremor.

Three right-handed patients diagnosed with Holmes tremor (HT), who suffered from pharmacotherapy-refractory tremor, were eligible for unilateral posterior subthalamic area deep brain stimulation (PSA-DBS). All patients were evaluated with the Fahn-Tolosa-Marin Tremor Rating Scale (FTMTRS) and Clinical Global Impression scale (CGI) before DBS, 6, and 12 months after the PSA-DBS as well as at the last follow-up. In all patients, we observed a significant improvement of tremor control as demonstrated by changes in the FTMTRS and the CGI scales. Mean improvement of tremor in all patients was 56% for the FTMRTS with a corresponding change in the CGI scale. Our study demonstrates that PSA-DBS is efficacious in the treatment of HT. Indeed, PSA is a promising target for DBS for intractable proximal and distal tremor, even in cases of previous, suboptimal functional neurosurgery. The beneficial effect lasts over a long-term follow-up. PSA-DBS may be considered as an alternative target of DBS in tremor treatment.

Astrocytoma malignum in glioblastoma multiforme vertens with long term survival--case report and a literature review.

Glioblastoma multiforme is the most common and most lethal pri- mary malignant tumor of the central nervous system. It can develop as a primary tumor or by transformation from its precursor--anaplastic astrocytoma which occurs less frequently but the prognosis is also unfavorable. Authors report a case of a 36-year-old man with "astrocytoma malignum in glioblastoma multiforme vertens" in the left frontal lobe. The mass, around 5 cm in diameter was resected by craniotomy 8 years ago. The patient received adiuvant radiation therapy concomitanly with temozolomide. He still stays asymptomatic, with no focal neurologic defects. There is no recurrence in the magnetic resonance imaging.

Efficacy of concomitant and adjuvant temozolomide in glioblastoma treatment. A multicentre randomized study.

BACKGROUND AND PURPOSE: The common treatment in patients with newly diagnosed glioblastoma multiforme is the ultimately radical surgical removal of the tumour combined with radiotherapy. This study compared safety and efficacy of radiotherapy alone with radiotherapy combined with temozolomide (TMZ) given before, during, and after radiotherapy. MATERIAL AND METHODS: The patients operated on for glioblastoma multiforme during the first 21 postoperative days were randomly assigned to the group treated with radiotherapy alone (involved-field radiotherapy in 2 Gy fractions daily five times a week up to the total of 60 Gy over 6 weeks of treatment) or to the group treated with radiotherapy and TMZ, initially in the dose of 200 mg/m² during 5 postoperative days and after 23 days followed by 75 mg/m2 of body surface area daily, 7 days a week (from the first to the last day of radiotherapy). On completion of radiotherapy, five complementary courses of TMZ were introduced (150-200 mg/m² for 5 days, repeated every 28 days). The primary outcome measure was overall survival. RESULTS: Fifty-eight patients from 3 centres were included in the study. The mean age of patients was 55 years and all the patients underwent a surgical procedure of glioblastoma removal. The mean overall survival in the group treated with TMZ was 16.0 months, whereas in the group with radiotherapy alone the overall survival reached 12.5 months. 24-month survival reached 23% in patients treated with TMZ and 6.7% in those who received radiotherapy only. Haematological complications of third or fourth degree were present in 10% of patients treated with radiotherapy and TMZ. CONCLUSIONS: The introduction of TMZ before, during and after radiotherapy for newly diagnosed glioblastoma multiforme gives clinically and statistically significant improvement of survival with unremarkably increased toxicity of the treatment.

A1/A2 polymorphism of GpIIIa gene and a risk of aneurysmal subarachnoid haemorrhage.

Platelet glycoproteins are involved in pathophysiology of cerebrovascular diseases. The aim of this study was to investigate the association between the GpIIIa gene A1/A2 polymorphism and a risk of aneurysmal subarachnoid haemorrhage (SAH) in a Polish population. In a case-control study we genotyped 288 Caucasian patients with aneurysmal SAH and 457 age-, gender- and race-matched controls. The GpIIIa A1/A2 polymorphism was genotyped with RFLP technique. No difference was found in the distribution of the polymorphism between the cases and controls (cases: A1A1-201 (69.8%), A1A2-83 (28.8%) and A2A2-4 (1.4%) vs. controls: A1A1-323 (70.7%); A1A2-128 (28.0%); A2A2-6 (1.3%), P>0.05. In a multivariate analysis female gender (OR=1.950; 95%CI: 1.308-2.907), hypertension (OR=4.774; 95%CI: 3.048-7.478) and smoking (OR=2.034; 95%CI: 1.366-3.030), but not GpIIIa A1/A2 polymorphism, were independent risk factors for aneurysmal SAH. The GpIIIa A1/A2 polymorphism is not a risk factor of aneurysmal SAH in a Polish population.

Colloid cysts of the third ventricle. Endoscopic and open microsurgical management.

BACKGROUND AND PURPOSE: The endoscopic approach to colloid cysts of the third ventricle is receiving increasing interest. However, its effectiveness is a matter of discussion. The aim of the study was to present direct and long-term outcome after endoscopy of colloid cyst vs microsurgery. MATERIAL AND METHODS: Medical records of 23 patients with colloid cysts were retrospectively analyzed. This group consists of 10 patients treated endoscopically and 13 patients treated using a transcortical-transventricular approach. Sex and age distributions were similar in both groups. Clinically, symptoms of raised intracranial pressure predominated. All patients had hydrocephalus. Tumour diameter ranged from 1.5 to 3 cm. Mean follow-up period was 31 months. RESULTS: In 6/10 endoscopically treated patients, tumours were completely removed. In 3 patients, small capsule remnants, adherent to the choroid plexus and veins, were left. In one case, a portion of capsule, obstructing the intraventricular foramen, was finally removed microsurgically. Postoperatively, 2 patients complained of memory deficits, which became permanent in one case. One patient developed temporary mutism. In one case, with symptoms of hydrocephalus without colloid cyst recurrence, a ventriculoperitoneal shunt was implanted 6 months after the initial surgery. In all microsurgically treated patients tumours were completely removed. One patient was reoperated because of intracerebral haematoma. Two patients suffered from temporary hemiparesis and 2 developed epilepsy. Within one year after surgery 3 patients were shunted because of hydrocephalus; one patient required antiepileptic treatment. CONCLUSIONS: The endoscopic approach to colloid cysts of the third ventricle is safe, effective and carries a low complication rate. Endoscopy may be recommended as a treatment option.

[Influence of anticoagulants on the appearance of chronic subdural hematoma]. / Wplyw leków przeciwzakrzepowych na wystepowanie przewleklego krwiaka podtwardówkowego.

In recent years in the Department of Neurotraumatology in Cracow it has been noticed the frequent connection between appearance of chronic subdural hematoma (CSDH) and treatment by anticoagulant medications. The aim of this study is to draw attention to the problem of insufficient control of anticoagulants consumption, especially by patients treated for cardiovascular system diseases that increases the risk of bleeding and CSDH development. The paper is based on data from questionnaires that was sent to patients with CSDH, cured in the Department of Neurotraumatology form 2004 to 2005. Analyzed was the group of 51 patients with chronic subdural hematoma; 37 individuals (72.5%) confirmed taking acetylsalicylic acid in the period of 3 months before admission to the Department, 9 (17.6%) patients answered that they were taking low-molecular weight heparin. One patient (1.9%) was taking chronically derivative of cumarin. The authors would inform that anticoagulant treatment might favour increase of chronic subdural hematoma incidence. It's especially important, because the average life expectancy has been prolonged in Poland and there are more people taking acetylsalicylic acid. This can be an epidemiological problem in future.

[Results of multidisciplinary treatment of frontal sinus fractures]. / Wyniki zespolowego leczenia obrazen zatok czolowych.

BACKGROUND AND PURPOSE: The aim of the study was to present the results of our management of frontal sinus fractures. MATERIALS AND METHODS: We analyzed records of 101 patients treated between 1996 and 2002, who sustained frontal sinus fractures. 7 patients were women and 94 were men. The average age of patients was 34 years. We analysed: circumstance of frontal sinus injury, frontal sinus fracture patterns, associated facial tissue and bone injuries, central nervous system injuries, perioperative management, timing of operation, surgical procedures and complications. RESULTS: 30 patients had anterior table fractures (type I), 51 had anterior and posterior table fractures (type II = 50, type IV = 1), 20 had posterior table fractures (type III). 22 patients were managed medically, 79 surgically. In 74 cases a combined, one-stage surgical procedure with neurosurgeons was performed, in 4 cases with an ophthalmologist, in 31 cases associated facial bone fractures were surgically managed. The average length of hospitalization was 16 days. There were 19 cases (24%) of postoperative complications, mostly early and late CSF leakage (12 patients). Inflammatory complications included acute frontal sinusitis (3 patients) and postoperative wound infection (1 patient). CONCLUSIONS: Multidisciplinary one-stage surgical treatment of patients suffering from frontal sinus fractures associated with central nervous system and facial injuries optimizes treatment results and minimizes postoperative complications. A significant reduction in early and late postoperative inflammatory complications confirms the efficiency of nasofrontal duct recanalization with frontal sinus reconstruction.

[Prognostic value of computerized rheoencephalography in chronic posttraumatic subdural hematoma: a preliminary report]. / Znaczenie prognostyczne badania reoencefalograficznego w przewleklym pourazowym krwiaku podtwardówkowym--doniesienie wstepne.

BACKGROUND AND PURPOSE: The results of treatment of chronic subdural hematoma (CSDH) are still regarded as unsatisfactory. Measurements of cerebral hemodynamics are increasingly used to elucidate the pathophysiology of mental disturbances and hemiparesis in CSDH. On the other hand the clinical studies of cerebrovascular autoregulation in this condition are almost nonexistent. This study was therefore conducted to assess the cerebral artery compliance and the status of the autoregulatory reserve in CSDH as well as their effect on the neurological outcome. MATERIAL AND METHODS: Ten patients with posttraumatic CSDH were studied. The status of cerebrovascular autoregulation and compliance of arteries were investigated using computerized rheoencephalography (REG). A classification of the pulse waveform (REGpw) has been devised according to the number of inflection points in the ascending branch. The normal cases have corresponded with only one inflection point (category I). The presence of three or more inflection points was thought as characteristic for regressive changes of the arterial wall (category II). The capacity of autoregulatory reserve was estimated by studying the changes in amplitude of REGpw as a response to upper body-down tilting. RESULTS: In all patients the REG examination revealed a reduction in autoregulatory reserve. In 3 patients with the worst clinical result of treatment bilateral impairment of cerebrovascular autoregulation was found. The reduction in compliance of arteries was revealed in 6 patients. CONCLUSIONS: Our preliminary results indicate that bilateral impairment of the cerebral blood flow and the decrease in arterial compliance are of prognostic significance in patients with CSDH.

[The role of computerized rheoencephalography in the assessment of normal pressure hydrocephalus. Preliminary report]. / Wartosc badania reoencefalograficznego w ustalaniu wskazan do leczenia operacyjnego pourazowego wodoglowia normotensyjnego. Doniesienie wstepne.

BACKGROUND AND PURPOSE: It is generally agreed that the positive result of lumbar cerebrospinal fluid (CSF) withdrawal offers a reliable means for selection of patients likely to respond to shunting in normal pressure hydrocephalus (NPH). However the studies of cerebral hemodynamics in NPH are performed Routinely only in few neurosurgical centers. We therefore studied the effect of CSF withdrawal on cerebrovascular autoregulation (CVA) in this condition by means of computerized rheoencephalography [REG]. MATERIAL AND METHODS: The study group consisted of 27 patients with presumed posttraumatic NPH. In each patient both the tap test and infusion test were performed. Psychometric tests and rheoencephalographic examinations were made twice: before and after CSF withdrawal. The obvious restoration of the functional state of CVA after CSF withdrawal was considered as a positive result of the tap test. RESULTS: Fourteen patients with a positive tap test and/or with resistance to CSF outflow (Rout) of more than 11 mmHg/ml/min were shunted. The improvement was obtained in 10 of them. Only one patient with a positive tap test did not improve. CONCLUSIONS: Our study suggests that restoration of CVA after CSF withdrawal is associated with high likelihood of shunt success, but not vice versa. Evaluation of CVA using REG seems to offer a new diagnostic tool in selecting patients likely to respond to shunting. Further studies are necessary to optimize the amount of CSF withdrawal, the delay between CSF withdrawal and control examinations and methodology of neuropsychological examinations.

[Circadian rhythms of melatonin of patients with severe traumatic brain injury]. / Badania rytmu dobowego melatoniny u chorych po ciezkim urazie czaszkowo-mózgowym.

The study was performed on a group of 5 patients with severe traumatic brain injury and in 2 healthy volunteers as the controls. The examination began 2-5 days after injury. The management of the patients and controls did not affect the natural melatonin circadian rhythm. The first result obtained was the characteristic nocturnal increase of the melatonin level in the healthy subjects. In a group of 5 patients with the severe traumatic brain injury the differences between the day and night time were insignificant. The results of the present study indicate that the severe brain injury gives rise to serious disturbances of the melatonin secretion in the acute posttraumatic period. These disturbances are characterized by the absence of the natural melatonin circadian rhythm. Despite the small number of patients, the obtained results justify further studies.

[Association of apoE polymorphism and treatment outcome in patients with traumatic brain injury]. / Badanie wplywu polimorfizmu apo E na wynik leczenia chorych z urazami czaszkowo-mózgowymi.

A number of papers published in recent years indicate the importance of the apolipoprotein E gene (apoE) for the outcome of traumatic brain injury [TBI]. A majority of publications suggest that the presence of an epsilon 4 allele is associated with an unfavorable long-term outcome. A hypothesis has been recently posed that this phenomenon may be related to an increased risk of traumatic hypoxic brain damage or post-traumatic ischemic complications. The study group consisted of 95 consecutive TBI patients treated in the years 2000-2001 in the Neurotraumatology Clinic. The presence of apoE epsilon 4 was found in 16 cases. In the statistical analysis relationship was sought between the patient's age and state of consciousness at admission as assessed using the Glasgow Coma Scale, on the one hand, and on the other hand, treatment outcome at 6 months from injury, in patients differing in respect of apoE epsilon 4 presence. Although the number of apoE-negative patients was nearly five times as large as that of the apoE-positive, regression coefficients in both groups were statistically significant. The obtained results indicate that the presence of apoE epsilon 4 contributes to a less favorable clinical TBI outcome than the absence of this allele.

[Traumatic epidural hematoma in a patient with von Willebrand's disease]. / Pourazowy krwiak nadtwardówkowy u pacjenta z choroba von Willebranda.

A case of traumatic epidural haematoma associated with von Willebrand disease (type 3) is reported. A 32-year-old man fell and hit his frontal region against the floor. CT scan on admission showed acute epidural haematoma of the right frontal region 45 mm in width and 60 ml volume. Considering moderate clinical symptomatology, a possibility of complication in connection with a congenital coagulation disorder and, above all, lack of patient's consent, prophylactic treatment with clotting factor concentrates was undertaken. Complete resorption of epidural haematoma has been obtained. In our opinion, in the presence of relative contraindication to operative intervention, even in cases with a large intracranial haematoma and inborn clotting deficiency prophylactic treatment may be considered. The following conditions must be met before such treatment is undertaken: prompt use of appropriate clotting factors, CT scan, clinical observation as well as possibility of prompt operative intervention in the neurosurgical department must all be available.

[Chronic subdural hematoma: a review of the literature. Part 1]. / Przewlekly krwiak podtwardówkowy--przeglad pismiennictwa. Czesc 1.

The first part of this publication is a review of the literature on the history, etiopathogenesis, clinical signs, and diagnosis of chronic subdural hematoma (CSDH). The incidence rate of CSDH is 2-11 cases per 100000 inhabitants. In spite of many anatomopathologic and biochemical studies, the pathomechanism of CSDH has not been fully explained. Although head computed tomography is the method of choice for the diagnosis of CSDH, magnetic resonance imaging can provide much more structural information on the hematoma. The pathophysiology of mental changes and hemiparesis in CSDH remains unclear. However, disturbances of cerebral haemodynamics seem to play a major role.

[Comparison of two surgical methods as to early results in chronic subdural hematoma]. / Porównanie wczesnych wyników leczenia dwiema metodami operacyjnymi chorych z przewleklym krwiakiem podtwardówkowym.

OBJECTIVE: Despite general agreement among neurosurgeons concerning operative treatment in chronic subdural hematoma (CSDH), the optimal procedure remains controversial. Two surgical approaches are available: evacuation of hematoma fluid by trepanation; craniotomy and removal of hematoma with surrounding membranes. The main goal of this study was to compare the results of treatment in CSDH depending on the method of surgery. MATERIAL AND METHODS: This retrospective study was done basing on case histories and computed tomography findings in 433 patients with CSDH operated between 1983 and 2003 at the Department ofNeurotraumatology, Jagiellonian University. Altogether, 495 neurosurgical procedures were done. Hematoma was managed by burr hole evacuation in 333 cases and by craniotomy in 162 cases. RESULT: Neurological grading on discharge indicated that trepanation produced significantly better results than craniotomy. CONCLUSIONS: (1) In comparison with literature data and by separate evaluation, the results of treatment in CSDH at the Department of Neurotraumatology were good in trepanation and craniotomy groups alike. (2) Literature data and case histories of the present study demonstrate that burr hole evacuation is the preferred method of treatment in CSDH. (3) In the overwhelming majority of cases, computed tomography fails to identify CSDH patients necessitating craniotomy.

[Chronic subdural hematoma: a review of the literature. Part 2]. / Przewlekly krwiak podtwardówkowy--przeglad pismiennictwa. Czesc 2.

The second part of this review is concerned with methods and results of treatment in chronic subdural hematoma (CSDH). Surgical evacuation is the generally accepted approach to treatment in CSDH. There are two neurosurgical methods of evacuation: 1. Burr hole in the cranial vault and evacuation of hematoma fluid. 2. Craniotomy and removal of hematoma with surrounding membranes. According to the literature, priority should be given to burr hole evacuation of the hematoma on the following premises: 1. High effectiveness with lower risk of complications and better treatment outcome for trepanation. 2. Craniotomy with removal of hematoma membranes, although radical, does not eliminate the risk of recurrence of hematoma. 3. Reduction in the volume of hematoma fluid through the burr hole and drainage may lead to total resorption of hematoma together with membranes.

[A comparison of the results of treatment in young and elderly patients with chronic subdural hematoma depending on the method of surgery]. / Porównanie wyników leczenia chorych mlodych i w wieku podeszlym z przewleklym krwiakiem podtwardówkowym z uwzglednieniem stosowanej metody operacyjnej.

INTRODUCTION: Chronic subdural hematoma (CSDH) generally occurs in patients past the age of 50 years but may develop at any age, also in young persons. The aim of this study was to compare the results of treatment in young and elderly patients with CSDH depending on the method of surgery: burr hole (group A) or craniotomy (group B). MATERIAL AND METHODS: This retrospective study was based on medical histories and computed tomography findings in patients with CSDH operated at the Department of Neurotraumatology, Jagiellonian University, in 1983-2003. Altogether, 114 patients were analyzed including 35 (30.7%) patients under the age of 40 years and 79 (69.3%) patients over the age of 75 years. RESULTS: A significant correlation between the result of treatment and age of patients with CSDH was demonstrated. The best result (Glasgow Outcome Scale = 5) was achieved in 73.9% of young patients in the trepanation group and in 66.7% in the craniotomy group as opposed to just 15.5% of elderly patients in the trepanation group and 4.8% in the craniotomy group. The difference between young and elderly patients was significant (p = 0.00001 for burr hole surgery, p = 0.0006 for craniotomy). Burr hole evacuation offered better results than craniotomy. CONCLUSIONS: (1) The results of treatment were much better in young than in elderly patients. (2) Comparison of the results of treatment of chronic subdural hematoma shows that burr hole surgery is the preferable procedure.

Morphological aspects of the traumatic chronic subdural hematoma capsule: SEM studies.

The morphology of the outer and inner membranes of traumatic chronic subdural hematomas (CSDHs) surgically removed from eight patients was investigated by scanning electron microscopy (SEM). Hematomas were divided into three groups based on time that had passed from the initiation of trauma to surgery. Structure of the CSDHs showed gradual morphological changes of the developing hematoma capsule. They initially included angiogenic and aseptic inflammatory reactions followed by progressive involvement of fibroblasts-proliferating and producing collagen fibrils. Numerous capillaries suggesting formation of new blood vessels were observed mainly in young hematomas removed between 15 and 21 days after trauma. In "older" hematomas (40 days after trauma), more numerous capillaries and thin-walled sinusoids were accompanied by patent, larger diameter blood vessels. Within the fibrotic outer membrane of the "oldest" hematoma capsules (60 or more days after trauma), especially in the area over the hematoma cavity, blood vessels were frequently occluded by clots. The results suggest dynamic changes in cellular and vascular organization of traumatic CSDH capsules paralleling the progression in hematoma age.