Safety and efficacy of treatment of very small intracranial aneurysms.

PURPOSE: Very small intracranial aneurysms (VSIAs) may cause many neurological complications and even death. Thanks to technological progress and higher quality of non-invasive neuroimaging methods, these pathologies can be investigated sooner and treated earlier. Due to the controversy surrounding invasive treatment of these pathologies, the aim of the study was to analyse methods of treatment, their outcome, and complications in a group of patients with VSIAs. MATERIAL AND METHODS: Out of 444 cases of intracranial aneurysms treated in our centre, 65 aneurysms met the radiological criteria of VSIAs. The parameters - width and length of the aneurysm's neck and width, length, and height of the aneurysm's dome - were measured. The analysed parameters were as follows: symptoms upon admission and after treatment, days in hospital, and intraoperative complications. Clinical and radiological intensity of subarachnoid haemorrhage (SAH) was evaluated by using the Hunt-Hess and Fisher scales. The degree of embolisation of the aneurysm after the procedure was assessed using the Montreal Scale. Clinical outcome was assessed by Glasgow Outcome Scale. RESULTS: 50.77% of VSIAs were treated with endovascular procedures and 49.23% with neurosurgical clipping. SAH was presented in 38.46% of patients with VSIAs. Intraoperative complications were presented in 16.92% of patients with VSIAs, and the most common complication was ischaemic stroke. Stents were used in 51.52% of VSIAs. In 69.70% of embolisation procedures at VSIAs complete obliteration was achieved. The average result in the Montreal Scale was 1.31 (SD = 0.66). CONCLUSION: VSIAs can be treated as effectively and safely as larger aneurysms, by both endovascular and surgical methods.

Stent-assisted embolization of wide-neck anterior communicating artery aneurysms: Review of consecutive 34 cases.

OBJECTIVE: We report our experience with stent-assisted coiling of anterior communicating artery aneurysms with special consideration of angiographic and clinical outcomes, retreatment rate and periprocedural complications. MATERIALS AND METHODS: The analysis included 34 consecutive ruptured and unruptured wide-neck aneurysms. The aneurysm size ranged from 2 to 18mm (mean 5.47). Clinical examinations with the use of modified Rankin Score and angiographic outcomes were evaluated initially post-embolization and at a minimum follow-up of 6 months. RESULTS: Initial post-treatment complete and near-complete aneurysm occlusion was achieved in 32 (94%) and 2 (6%) cases, respectively. Imaging follow-up, performed in 28 (82%) patients, showed no change in the degree of occlusion in 25 (89%) cases and coil compaction in 3 (11%) patients. Of these, one (3.6%) patient underwent a second coil embolization. The periprocedural severe complication rate was 2.9% (1/35) and was associated with prolonged attempt of retrieval of migrated coil resulting in anterior cerebral artery infarct with serious clinical consequences. In another 3 patients periprocedural adverse events without delayed clinical consequences were noticed. The clinical follow-up evaluation achieved in 33 (97%) patients showed no change in 30 (91%) cases, one patient (3%) with clinical improvement and two (6%) cases of neurological deterioration. CONCLUSIONS: The use of stent is feasible and effective for coil embolization of wide-necked anterior communicating artery aneurysms. Although periprocedural complications resulting in severe morbidity are rare, they should be noted, since in terms of thromboembolic events some of them presumably have a potential to be avoidable.

Stent-Assisted Endovascular Treatment of Anterior Communicating Artery Aneurysms - Literature Review.

The anterior cerebral artery is a common location of intracranial aneurysms. The standard coil embolization technique is limited by its inability to occlude wide-neck aneurysms. Stent deployment across the aneurysm neck supports the coil mass inside the aneurysmal sac, and furthermore, has an effect on local hemodynamic and biologic changes. In this article, various management strategies and techniques as well as angiographic outcomes and complications related to stent-assisted endovascular treatment of anterior communicating artery aneurysms are presented. This treatment method is safe and associated with low morbidity and mortality rates.

Endoscopic technique in the treatment of patients with colloid cysts of the third ventricle. Report based on over a decade of experience.

BACKGROUND AND PURPOSE: The aim of the work was a retrospective analysis of the efficiency of endoscopic treatment of patients with colloid cysts of the third ventricle. MATERIAL AND METHODS: The analysis covered 17 patients. There were 19 operations in total. The follow-up period ranged from 21 to 130 months. The effectiveness of the method was evaluated by comparing neurological condition and magnetic resonance imaging (MRI) before and after treatment. RESULTS: The mean duration of surgery was 81 minutes. The cyst was removed completely in 8 patients, subtotally in 5, partially in 3, and in 1 case a biopsy was performed. No persistent intra- or postoperative complications or deaths occurred. Immediately after the operation symptoms withdrew completely in 8 patients and partially in 9. In the long term follow-up period, all symptoms receded completely in 11 patients and a further 6 patients showed partial improvement. MRI revealed the absence of the cyst in 8 patients, in 2 patients the tumor was smaller in size and in a further 7 patients some small parts of the walls of the cyst were present. The width of the ventricle system returned to its normal size in 8 patients, decreased in 8 patients and in 1 case remained at its initial size. In 2 patients temporary postoperative complications occurred. The average hospitalization time was 9 days. CONCLUSIONS: Recurrences of colloidal cysts after subtotal and partial removal do not occur very often, and the time of the recurrence may either be very long or it may not happen at all. Although we recommend complete removal of the cyst, this should not be pursued at the cost of incurring operative complications.

Increase in activity of neutrophils and proinflammatory mediators in rats following acute and prolonged focal cerebral ischemia and reperfusion.

PURPOSE: It has been proposed that the immune system is activated during ischemic cerebral events and that brain damage caused by ischemia is increased by this immune activity. Neutrophils (PMNs) are one of the first factors in the chain of reactions of the immune system during focal cerebral ischemia. Experimental and clinical studies have emphasized the important role of proinflammatory cytokines such as interleukin-1beta (IL-1beta) and tumor necrosis factor (TNFalpha), in addition to vasoactive peptide and endothelin-1 (ET-1), in the formation of cerebral ischemia. MATERIAL AND METHODS: The experiments were carried out using Wistar rats that were divided into four groups: three experimental groups (acute and prolonged focal cerebral ischemia and following reperfusion) and one control group (sham). Focal cerebral ischemia was induced by the intraluminal surgical suture method. The oxidative activity of PMNs was measured after stimulation with phorbol myristate acetate, a protein kinase C activator (luminol enhanced chemiluminescence). The concentration of IL-1beta and TNFalpha in rat lymphocyte culture after stimulation with CSF was determined using commercial ELISA kits. The plasma concentration of ET-1 was determined using commercial kits with the RIA method. RESULTS: We confirmed a statistically significant increase in the oxidative activity of PMNs in rats with acute focal cerebral ischemia (p < 0.00001), prolonged ischemia (p < 0.001) and reperfusion (p < 0.05). An increase in IL-1beta and TNFalpha in lymphocytes following CSF stimulation was observed in the group with prolonged ischemia and in the group with reperfusion after transient ischemia (p < 0.05 for both). An increase in plasma ET-1 concentration was observed with acute and prolonged focal cerebral ischemia (p < 0.05 and p < 0.01, respectively). CONCLUSIONS: Our results show that acute and prolonged focal cerebral ischemia and reperfusion induce statistically significant increases in the oxidative activity of PMNs. The concentration of proinflammatory mediators (IL-1beta, TNFalpha) as well as ET-1 is also increased, indicating the important role of immune reactions in the development of damage to the brain following ischemia.

Decompressive hemicraniectomy in ischaemic stroke.

BACKGROUND AND PURPOSE: Hemispheric ischaemic stroke complicated by oedema is associated with high mortality. The results of randomized studies showed that decompressive hemicraniectomy performed in this group of patients could be beneficial. First experiences with implementation of hemi-craniectomy in patients with brain infarct in our stroke centre are presented. MATERIAL AND METHODS: Between August 2007 and July 2008, four patients with hemispheric brain infarcts complicated by malignant oedema underwent decompressive hemicraniectomy within 72 hours from symptoms onset. Stroke severity was assessed with the National Institutes of Health Stroke Scale (NIHSS). Clinical outcome was assessed 3, 6 and 12 months after the event using the modified Rankin scale (mRS). RESULTS: In the first patient, the neurosurgical procedure included only decompressive hemicraniectomy, whereas in the other three duraplasty was performed additionally. The first patient died 23 days after the stroke onset due to acute respiratory failure. Another died at four months after the event, due to infectious complications. The remaining two patients presented severe functional disability 12 months after the procedure (mRS score 4). CONCLUSIONS: Decompressive surgery with duraplasty can be a life-saving procedure for patients with brain oedema. To our knowledge, the presented cases are among the first reported cases of hemispheric ischaemic stroke treated with decompressive hemicraniectomy in Poland. Extended follow-up with a larger group of patients is necessary to assess long-term outcome.

Rupture during coiling of intracranial aneurysms: Predictors and clinical outcome.

INTRODUCTION: The intraprocedural aneurysm rupture (IPR) is one of the most feared adverse effect associated with the coil embolization therapy. The aim of the study was to identify predisposing factors for IPR, as well as to define patient groups with worse clinical outcome following IPR. PATIENTS AND METHODS: From February 2008 to March 2015, 273 consecutive patients were treated at our institution via endovascular coil embolization. Patient medical records were reviewed with emphasis on procedure description, potential risk factors and clinical outcomes related to IPR. The IPR occurred in 14 (5.13%) cases. Multivariate logistic regression models were used to determine independent predictors of IPR. Clinical outcome was analyzed using the Glasgow Outcome Scale (GOS). RESULTS: Multivariate analysis showed that aneurysm location at posterior communicating artery is an independent risk factor for IPR (p = 0.035; OR 3.5; 95%CI 1.09-11.26). The frequencies of favorable disability (GOS 4-5), severe disability (GOS 2-3), and mortality (GOS 1) between patients with IPR and without IPR were significantly different in the general study population (p < 0.001, p < 0.001 and p = 0.023, respectively) and in patients with previously unruptured aneurysms (p < 0.001, p = 0.006 and p = 0.003, respectively) but not in patients with previously ruptured aneurysms (p = 0.187, p = 0.089 and p = 1.0, respectively). CONCLUSION: Posterior communicating artery aneurysm location is an independent predictor for IPR. IPR is associated with a significant clinical deterioration in a subgroup of patients with previously unruptured aneurysms, but not in patients with ruptured aneurysms.

Primary pituitary lymphoma.

Primary CNS lymphoma (PCNSL) is now thought to constitute 3% of all intracranial neoplasms. PCNSL occurrence in the sella turcica region is an extremely rare finding. We present a 37-year-old male with primary pituitary lymphoma treated in our department. The patient, who had had no previous illnesses, was admitted to the hospital because of bilateral blurred vision. Findings on physical examination were normal except for temporal parts of field of vision deficit. No abnormalities were found in his bilateral ocular movement, facial sensory function or motor function. His blood count and biochemical profile were normal. Basic hormonal studies revealed no symptoms of panhypopituitarism. MRI demonstrated a large intrasellar mass with supra- and parasellar extension. MRS revealed decrease in NAA/tCr proportion and increase in Cho/NAA and Cho/tCr proportions. Endoscopic surgery was performed using the transsphenoidal approach. Histopathological examination demonstrated a large B-cell lymphoma. The patient received 6 cycles of CHOP chemotherapy. He was also irradiated with 6 MV photons to the whole brain to a total dose of 40 Gy and then there was a boost to the tumour to a total dose of 50 Gy. Next he was reoperated on with the fronto-temporo-sphenoidal craniotomy approach and subtotal resection of the tumour was performed. After the treatment the visual disturbances significantly decreased. Control MRI revealed a stable remnant of the tumour. Nowadays the patient has 52 months' follow-up and he has only a stable, slight visual field deficit on the upper temporal side of the right eye.

Idiopathic hypertrophic pachymeningitis - case report and literature review.

Idiopathic hypertrophic pachymeningitis (IHPM) is a rare pathological state, with still unclear aetiopathogenesis. We present a case of a 63-year-old woman with cranial variety of that disease. The manifestations of the disease included headaches, paresis of VI, IX, X nerves and cerebellar ataxia. The disease was diagnosed with magnetic resonance imaging (MRI) and histopathological assessment of the pachymeninx biopsy specimen. The MRI revealed significant thickening of the cranial base pachymeninx, compressing the pons and medulla oblongata. MRI examinations could be misinterpreted as extensive meningioma of the skull base. Dura mater biopsy revealed however inflammation with abundant lymphocytic infiltrations. Clinical improvement was obtained after the application of corticosteroids. We noted the subsidence of all symptoms of the disease, as well as radiological improvement, manifested through substantial regression of the described changes in the pachymeninx. The patient has been presented in the context of 65 cases of idiopathic hypertrophic pachymeningitis, described in the literature of English-speaking countries in the last five years. Recently, the importance of the autoimmunogenic background of IHPM has been underlined. In that respect IHPM has become an interdisciplinary problem. Its diagnosis and treatment requires not only radiologists, neurologists, pathomorphologists and neurosurgeons, but also specialists in internal medicine, including immunologists, allergologists and rheumatologists as well - in other words, physicians that rarely take part in the processes of diagnosing and treating intracranial pathologies.

Endoscopic transsphenoidal treatment of hormonally active pituitary adenomas.

AIM OF THE STUDY: The paper presents endoscopic surgical technique used in the treatment of hormonally active pituitary adenomas and assessment of the method in terms of its effectiveness and safety. MATERIAL AND METHODS: In 217 cases the surgery was performed due to pituitary adenomas applying the technique developed by Jho and Carrau, with our own modifications. 70 patients were treated for hormonally active adenomas. The group consisted of 36 somatotrophic adenomas, 21 prolactinomas and 13 corticotrophic adenomas. There were 51 females and 19 males with mean age of 42.6 years (range 11-77 years). The follow-up period was between 7 and 56 months (mean - 34 months). The effectiveness and occurrence of complications were confirmed on the basis of neurosurgical, laryngological, endocrinological, ophthalmological examinations and neuroimaging. RESULTS: Biochemical and neurosurgical criteria for complete resection were obtained in 21 (58.3%) of 36 patients with all somatotrophic adenomas. In the group of prolactinomas complete resection was achieved in 17 (80.9%) of 21 patients. Of the 13 patients with Cushing's disease 11 (84.6%) were cured. In the studied group there were no deaths. In the postoperative course only 2 (2.8%) patients suffered liquorrhoeas and new anterior lobe pituitary insufficiency was noted in 8 (11.4%) cases. Meningitis was noted in 1 (1.4%) case and another 1 (1.4%) patient had epistaxis which required repeated endoscopic surgery. CONCLUSIONS: Endoscopic technique is an effective method of treatment of hormonally active pituitary adenomas. It is characterised as being minimal invasive and has a low severe complication rate.

[The evaluation of the brain arteriovenous malformations' operative treatment in the clinical material of Silesian Medical University's Departament of Neurosurgery]. / Ocena wyników operacyjnego leczenia naczyniaków tetniczo-zylnych mózgu w materiale Kliniki Neurochirurgii w Katowicach.

UNLABELLED: A risk of haemorrhage in arteriovenous malformations (AVM) of the brain is estimated as 2-4% per year. A mortality rate from this reason is estimated as 1% per year and morbidity 10-20%. The methods of treatment ofAVM are: microsurgical treatment, radiosurgery, endovascular treatment. The aim of this work is presentation of our results of surgical treatment of AVM and comparison with the results of radiosurgical and endovascular treatment presented by other authors in the literature. MATERIAL AND METHODS: Between 1990-2002 in the Department of Neurosurgery of Medical University of Silesia in Katowice 31 patients were operated with AVM's of the brain. Among them there were 10 female and 21 male at the age from 10 to 69 years. The average age was 36.1. The first sign was intracranial haemorrhage in 19 cases and epileptic seizures in 9 cases. In all cases the cerebral angiography was performed and all patients were assessed as I to III score according to the Spetzler-Martin scale. All patients were operated on using microneurosurgical techniques. The total removal of the tumour was assessed using the intraoperative Doppler examination. The state of the patients at the discharge was estimated according to Glasgow Outcome Scale (GOS). RESULTS: In all cases the malformations were removed totally. In 2 cases (6.4%) we noticed the deterioration of neurological condition after operation. The state of 28 patients (90.3%) was assessed as very good and good (I or II score) according to GOS at the discharge. We didn't notice any mortality in our group of patients. CONCLUSIONS: In the conclusion we want to emphasize the advantages of surgical treatment of AVM's of the brain especially these including in I to III score according to Spetzler-Martin scale comparing with the results ofradiosurgical and endovascular methods of treatment.

Stand-alone coil embolization of anterior communicating artery aneurysms: Efficacy and technical issues.

OBJECTIVE: We report our experience with endovascular coiling of anterior communicating artery aneurysms with special consideration of angiographic and clinical outcomes and periprocedural complications. MATERIALS AND METHODS: The analysis included treatment results of 28 patients with ruptured and unruptured aneurysms. The aneurysm size ranged from 1.8 to 9.8 mm (mean 5.2, SD 1.7). Clinical examinations with the use of modified Rankin Score and angiographic outcomes were evaluated initially post-embolization and at a minimum follow-up of six months. RESULTS: Initial post-treatment complete and near-complete aneurysm occlusion was achieved in 27 (96%) cases and incomplete occlusion in one (4%) case. Imaging follow-up, performed in 15 (53.6%) patients, showed no change in the degree of occlusion in 11 (73%), coil compaction in one (7%) and progressive occlusion in three (20%) patients. Three (20%) patients underwent a second coil embolization. The procedure-related severe morbidity and mortality rate was 6.4% (2/31). Coil prolapse was present in one (3.2%) case and intraprocedural aneurysm rupture in three (9.6%) cases. The clinical follow-up evaluation achieved in 19 (67.9%) patients showed no change in 17 (89.5%) patients and improvement in two (10.5%) patients. CONCLUSIONS: Although the efficacy of coil embolization of anterior communicating artery aneurysms is unquestionable and the procedure-related complications are acceptable, they should not be neglected. Further investigations are needed to better understand protective factors, as well as to establish unequivocally appropriate management strategy of these complications.

Molecular classification of pituitary adenomas: in search for criteria useful for high-throughput studies.

INTRODUCTION: The mechanism of pathogenesis of pituitary adenomas is still unknown, and it shows differences in pituitary cells of different origin. The aim of our study was to analyse the gene expression profile of pituitary hormones and their precursor genes: PRL, GH, POMC, TSHb, LHb, FSHb, and CGA by QPCR in particular types of pituitary adenomas, and to evaluate the results in the context of sample selection for microarray studies. MATERIAL AND METHODS: Analysis of the gene expression profile was performed in 84 samples of pituitary adenomas, by real-time quantitative PCR (QPCR). RESULTS: As expected, expression of GH gene was significantly higher in somatotropinomas than in prolactinomas (p < 0.05). For POMC gene we noticed lower expression in all pituitary adenomas, except adrenocorticotropinomas (p < 0.05). In the case of PRL gene, the highest expression was observed; PRL+ adenomas were in third place. LHb and FSHb genes showed the highest expression, respectively, in LH-producing and FSH-producing pituitary adenomas; however, our analysis did not show statistically significant differences between LH-producing and FSH-producing adenomas. CONCLUSIONS: Our study showed that GH is a characteristic gene for somatotropinomas. We drew a similar conclusion for POMC gene and adrenocorticotropinomas. However, the results that we obtained for PRL, TSHb, LHb, FSHb, and CGA genes indicate that evaluation of gene expression is not sufficient for classification of particular subtypes of pituitary adenomas.

[Endoscopic transsphenoidal treatment of pituitary adenomas]. / Endoskopowe leczenie gruczolaków przysadki.

BACKGROUND AND PURPOSE: The aim of this study is to present a new endoscopic transnasal transsphenoidal method of surgical treatment of pituitary adenomas and to evaluate the results and complications of the method. MATERIAL AND SURGICAL TECHNIQUE: From October 2001 to June 2003 in the Department of Neurosurgery of the Medical University of Silesia in Katowice 88 operations of pituitary adenomas were performed using the transnasal transsphenoidal endoscopic method. The group of patients consisted of 50 females and 38 males. The youngest patient was 11 years old and the oldest was 79 years old. Patients were operated on using the 4-mm diameter endoscope with 0- and 30-degree angled lenses, using a method of operation according to Jho and Carrau with own modifications. At the time of surgery the operation team included 2 neurosurgeons, an anesthesiologist and a laryngologist. RESULTS: In the group of 51 nonfunctioning adenomas, in 32 cases we obtained the total removal of the tumor, which amounts to 63%. Among 37 of hyperfunctioning adenomas there were 11 prolactinomas, 19 GH secreting adenomas and 7 ACTH secreting adenomas. In all cases of prolactinomas the tumor was removed totally and in the cases of GH secreting adenomas and ACTH secreting adenomas the total removal of the tumor was performed in 58% and 86% of the cases, respectively. One patient within our group died after the operation. It was the patient with a huge nonfunctioning macroadenoma, with hydrocephalus and preoperative disturbances of consciousness. The permanent diabetes insipidus occurred in 2 cases, which amounts to 2.3% of all operated patients. In this group we noticed the intraoperative CSF leakage in 20 cases but we did not observe the postoperative CSF leakage or any rhinological complications. CONCLUSIONS: The endoscopic transnasal transsphenoidal approach is an efficient method of surgical treatment of pituitary adenomas. The advantage of this method is low invasiveness and a small number of serious complications.

[Cavernous angiomas in the Department of Neurosurgery in Katowice]. / Naczyniaki jamiste w Klinice Neurochirurgii w Katowicach.

166 patients with arterio-venous malformations (AVM) were treated in the Department of Neurosurgery at Silesian School of Medicine from 1987 to 2002. There were 30 (18%) patients diagnosed as cavernous angioma (CA). The oldest treated patient was 73 years old and the youngest one was 5 years old. 16 (55%) male and 14 (45%) female were examined and the results of this examination are presented below. The location of CA was as follows: supratentorially--19 patients (64%), infratentorially--6 patients (20%), extracranially--5 patients (16%). During the admission the clinical status of patients were evaluated according to Glasgow Coma Scale (GCS) and Hunt-Hess scale (H-H). Epilepsy occurred in 5 patients (16%), neurological focal deficits--14 (45%), intracranial hemorrhage--7 (23%). All patients were examined using CT (computer tomography) scan, cerebral angiography was carried out in 15 (50%) patients and MRI (magnetic resonance imaging) in 16 (55%). All patients were operated on in our medical centre. The results of treatment were presented according to Glasgow Outcome Scale (GOS).

Correlation of facial nerve paresis and histopathological type of vestibular schwannoma.

The objective of the study was to evaluate the dependence of facial nerve paresis, as a symptom of cerebellopontine angle tumour, on the histopathological subtype of vestibular schwannoma, diagnosed from a post-operative histopathological examination. We retrospectively analysed 91 surgically treated patients with vestibular schwannoma. We studied the histopathological subtype and the preoperative condition of the facial nerve. The following WHO 2000 subtypes were distinguished: neurinoma cellular (51 cases), neurinoma conventional (23 cases), neurinoma ancient (11 cases), (other types: 2 neurofibroma and 2 ganglioneuroma). We analysed the dependence of facial nerve paresis on the histological subtype of tumours and their sizes. The analysis was based on the traditional classification: Antoni A (11 cases), Antoni B (12 cases) Antoni A/B (23 cases) and Antoni B/A (40 cases). 30 patients (30%) in the analysed group had paresis of the facial nerve preoperatively. Preoperative facial paresis occurred frequently in subtypes "cellular" and Antoni B, and rarely in subtypes conventional and Antoni A and B/A. In the small tumour cases (up to 20 mm), facial nerve paresis occurred frequently in subtypes cellular and conventional, as well as in Antoni A and A/B.

Non-neoplastic, degenerative brain pathologies and fibroses diagnosed on the basis of ultra-small samples obtained by stereotactic biopsy.

Brain biopsy and other stereotactic procedures have evolved over the last decades. Recently, the morbidity and mortality decreased radically along with an increase in the number of successful histopathological diagnoses. Therefore, applications of appropriate treatments in neoplastic brain pathologies are now possible, especially of those located in deep regions. Stereotactic biopsy may also be used as a diagnostic method followed by appropriate management in conditions where a non-neoplastic pathology is suspected. Between December 2000 and February 2004, we performed 116 stereotactic procedures based on the system of stereotactic planning and Brain-Lab treatment, which was equipped with automatic CT/MR image fusion software. In this report, we have focused on 10 cases of non-neoplastic brain pathologies diagnosed on the basis of ultra-small samples obtained from stereotactic biopsy. Among them there were 4 cases of gliosis, 3 cases of brain degenerative disorders, 2 cases of hippocampal fibroses, and 1 case of normal brain tissue. We have presented all these cases in detail by discussing their histology, clinical manifestations, localisation, management and follow-up.

Intraoperative monitoring of cochlear function using distortion product otoacoustic emissions (DPOAEs) in patients with cerebellopontine angle tumors.

HYPOTHESIS: Intraoperative monitoring by distortion-product otoacoustic emissions reflects the cochlear function changes in the real-time domain during removal of cerebellopontine angle tumors. BACKGROUND: Cerebellopontine angle tumor surgery is associated with a significant risk of damaging internal auditory canal contents. Although monitoring facial nerve function intraoperatively has already been effectively developed, such efficacious monitoring of auditory function remains to be established. The aim of this study was to investigate the utility of distortion-product otoacoustic emissions for intraoperative monitoring of the cochlear function in humans during removal of cerebellopontine angle tumors. METHODS: Continuous intraoperative monitoring of distortion-product otoacoustic emissions was performed in 20 of 62 patients undergoing surgical removal of cerebellopontine angle tumors. All of these 20 patients, who underwent the retrosigmoid approach, had distortion-product otoacoustic emissions present preoperatively. Depending on the amplitude and frequency band at which distortion-product otoacoustic emissions were present, monitoring was carried out at 2.0 to 6.0 kHz with primary stimulus tone amplitudes of 60 to 70 dB sound pressure level. RESULTS: In patients operated on for cerebellopontine angle tumors, various patterns of distortion-product otoacoustic emission amplitude reductions and recoveries were observed. Distortion-product otoacoustic emissions recorded from the basal part of the cochlea (i.e., high frequencies) changed earlier and more profoundly than those from the middle and apical sections (i.e., lower frequencies). In some cases, cochlear function was affected irreversibly as reflected by loss of distortion-product otoacoustic emissions. Microcoagulation of small vessels, tumor debulking, and compression or stretch of the internal auditory canal contents were found to be procedures affecting distortion-product otoacoustic emissions. The status of distortion-product otoacoustic emissions at the conclusion of tumor dissection correlated with postoperative hearing levels. CONCLUSION: Distortion-product otoacoustic emissions were used to monitor in the real-time domain auditory function during cerebellopontine angle tumor removal operations. The status of distortion-product otoacoustic emissions at the conclusion of the operations was related to postoperative hearing.

Melatonin secretion in patients with pineal region tumors-preliminary report.

Tumors of the pineal region, though not very common, are recently more often diagnosed due to the introduction of computer tomography and magnetic resonance examinations into neurosurgical practice. However many controversies about the treatment of them still exist. Some of them need aggressive treatment. The others are benign and asymptomatic. Thus it seems to be important to improve our diagnosis of mass lesion of the pineal region, especially before taking a decision for surgery. The purpose of this study was to find any significant changes in the circadian pattern of melatonin secretion in patients with pineal region tumors. Blood samples were collected preoperatively from 21 patients with diagnosed pineal region tumors. In 13 patients sampling was performed at 08:00, 14:00, 20:00 and 02:00 h during a 24-hour period but in 8 former ones only at 02:00 h at night. The samples were immediately centrifuged and the serum stored at -20 degrees C until analysis. The patients stayed in the darkened room from 23:00 to 05:00 h. Plasma melatonin was measured by direct and specific radioimmunoassay. The following three groups of results were found: (1) eight patients showed normal melatonin secretion profiles, (2) six cases with lack of the night maximum plasma value, and (3) seven cases with nocturnal melatonin concentration higher than in the healthy population (>100pg/ml). We observed no correlation between melatonin secretion and histological type of tumor. In conclusion, we suggest that changes of melatonin secretion could indicate the pineal region pathology. However further studies with a larger group of patients, especially with tumors originating from the pineal gland (pinealocytoma, pinealoblastoma), are necessary.

Simultaneous radiotherapy and radioimmunotherapy of malignant gliomas with anti-EGFR antibody labelled with iodine 125. Preliminary results.

BACKGROUND: In this paper we present the preliminary results of a prospective trial of the efficacy of simultaneous radiotherapy and anti-EGFR (125)I radioimmunotherapy of malignant gliomas with 2 years' total survival as the end-point, raising the question whether anti-EGFR (125)I radioimmunotherapy influences the disease-free survival in these patients. MATERIAL AND METHODS: Patients with anaplastic astrocytoma or primary glioblastoma were previously treated by a macroscopically radical neurosurgical approach and randomized either to radiotherapy + radioimmunotherapy arm or treated by radiotherapy alone. Seven patients were included in the group with radioimmunotherapy, among them five with GBM and two with AA, and five patients in the control arm. Patients were irradiated to 60 Gy using three-dimensional conformal noncoplanar techniques. Anti-EGFR (125)I monoclonal antibody 425 radioimmunotherapy (50 mCi/course) was started during 4th week of radiotherapy and was repeated three times in one week intervals. RESULTS: Time of follow-up ranges between 2 and 10 months in the anti-EGFR (125)I radioimmunotherapy arm and 4 and 9 months in the control arm. Recurrence was diagnosed in all patients in the EGFR (125)I group with a lethal outcome in two of them and in 4 patients in the control group. Median time to recurrence was 2 and 5 months respectively. CONCLUSIONS: Taking into account early recurrences observed, we propose to continue the studies on the efficacy of adjuvant anti-EGFR (125)I radioimmunotherapy in a selected group of patients in whom the greatest benefit may be expected on the basis of molecular studies, among them EGFR expression investigation.