Endovascular therapy for vasospasm after aneurysmatic subarachnoid hemorrhage.

INTRODUCTION: Balloon angioplasty and/or selective intra-arterial vasodilator therapies are treatment options in patients with vasospasm after subarachnoid hemorrhage (SAH). We analyzed the effect of balloon angioplasty and/or selective intra-arterial vasodilator therapy in our patients. METHODS: Twenty-six patients (vasodilation group, VDT) were treated with intra-arterial nimodipine. The balloon angioplasty with nimodiopine-group (BAP-N group) comprised 21 patients. The primary endpoint of this study was successful angiographic vessel dilation in vasospastic vessels after balloon angioplasty, together with nimodipine (BAP-N group), compared to intra-arterial vasodilator therapy (VDT group) with nimodipine alone. RESULTS: A significant effect of angioplasty plus nimodipine was found in the central arteries (composite endpoint) with an OR of 2.4 (95% CI: 1.4-4.2], p = 0.002), indicating a chance of improvement of the BAP-N group of more than twice compared to nimodipine infusions alone. Significant advantages for BAP-N-therapy were also encountered in the internal carotid artery (OR 5.4, p < 0.001) and basilar artery (OR 29.7, p = 0.003). A joint analysis of all arteries combined failed to show significant benefit of BAP-N therapy (OR 1.5, p = 0.079), which was also true for cerebral peripheral arteries (OR 0.77, p = 0.367). There was no difference in clinical outcome between both groups. CONCLUSIONS: In SAH patients with vasospasm, a combination therapy of balloon angioplasty and intra-arterial nimodipine resulted in a more than doubled vasodilative effect in the central cerebral arteries compared to the sole infusion of nimodipine. Regarding the ICA and BA arteries, this beneficial effect was even more pronounced. Although there was a tendency of better effects of the BAP-N group, regarding the overall effect in all territories combined, this failed to reach statistical evidence. In cerebral peripheral arteries, no differences were observed, and there was no difference in clinical outcome, too.

Towards a glioma model for surgical technique evaluation in the rat.

INTRODUCTION: Evaluation of new surgical techniques in animal models is frequently challenging. This article describes the pitfalls, peculiarities and the final best applicable model for evaluating surgical techniques for glioma resection. METHODS: The C6 glioma cell line and the Sprague-Dawley rat strain were selected. Fifty-thousand glioma cells were stereotactically transplanted in the left hemisphere of 137 male adult rats. Evaluation of solid tumour formation, tumour growth and scheduling of surgical resection was performed by MR scanning at 1, 2, and 4 weeks after transplantation and 3 and 6 months after tumour resection. Microsurgical tumour resection was performed with conventional techniques or with the waterjet dissector at a pressure of 6 bar. One subgroup of each surgical technique was sacrificed directly after surgery for histological analysis. The other subgroup was followed up for long-term analysis. RESULTS: The transplantation site was of great importance. After transplantation of tumour cells posterior to the bregma, intra-ventricular tumour growth with spreading occurred. Homogenous and reproducible tumour growth was achieved after grafting cells lateral - 3 mm, anterior + 1 mm, and - 2.5 mm ventral to the bregma. After development of solid tumours on MR imaging, animals were subjected to surgery. MR and intra-operative findings corresponded well. However, MRI and intra-operative none-detectable perivascular tumour spreading was histologically observed in the majority of cases. CONCLUSIONS: The presented glioma rat model consisting of the C6 cell line and Sprague-Dawley rats as recipients is a well-suited model to investigate surgical techniques and their impact on tumour therapy. However, the site of transplantation, the preparation of cell grafts and the technique of tumour growth evaluation is of utmost importance to achieve reliable results.

Involvement of jugular valve insufficiency in cerebral venous air embolism.

BACKGROUND: Cerebral venous air entrapment is a rare finding on cranial computed tomography (CT) scan. Peripheral air embolism is discussed as a potential cause. However, the mechanism of retrograde passage through internal jugular valves and veins is unclear. CASE REPORT: The case of a patient is reported, who had air entrapment in the left cavernous sinus. Prior to CT scanning, a peripheral intravenous line had been placed. Ultrasound revealed excessive insufficiency of the left internal jugular valve. To further study the mechanism of embolism, an echo contrast agent was injected into the cubital vein. A Valsalva maneuver resulted in retrograde transition of microbubbles across the insufficient valve. Valvular function on the unaffected right side was intact. CONCLUSIONS: This case report gives insight into the mechanism of cerebral venous air embolism. This is the firstcase describing jugular valve insufficiency as the missing link between peripheral air embolism and cerebral venous air entrapment.

Resection of C6 gliomas in rats with the aid of the waterjet technique.

OBJECTIVES: While clinically the safety and efficacy of waterjet resection of brain tumors have been shown, evidence that waterjet dissection improves tumor resection radicality in comparison with conventional techniques is still missing. In the present study, resection radicality and tumor-free long-term survival of both techniques were evaluated in a C6-glioma model. MATERIAL AND METHODS: Fifty-thousand C6-glioma cells were stereotactically transplanted in the left frontal lobe of 100 male Sprague-Dawley rats. After MRI-scanning for evaluation of tumor extension, microsurgical tumor resection was performed with conventional techniques (n=50) or with the waterjet dissector at pressures of 6bar (n=50). Twenty-five animals of each group were sacrificed after surgery for histological analysis. For analysis of survival after tumor resection, twenty-five animals of each group were followed-up to analyze tumor-free survival using the Kaplan Meier method. RESULTS: In the waterjet group, the resection cavity was free of C6-tumor cells in 10/25 (40%) rats showing a trend (p=0.3) towards better resection radicality compared to the rats that were treated conventionally (7/10; 28%). R1-resection with up to 250C6 cells/object slice was found in 14/25 (56%) rats after waterjet dissection compared to 6/25 (24%) rats treated conventionally showing significance (p<0.01). Probability of survival was 38% after 2 weeks and 20% after 6 months in the waterjet group compared to 30% and 16% respectively in the conventional group. Diffuse tumor cell spreading with possible influence on survival was shown in 47/50 rats. CONCLUSION: In this experimental model, waterjet tumor resection did reveal significantly better resection radicality compared to the conventional technique. Although a direct transfer of these results to human glioma surgery is prohibited, the waterjet technique might contribute to the best possible resection radicality in human gliomas. Nevertheless, tumor cell spreading remains a major problem. Further studies have to address that the surgical results - in deed - improve the postoperative outcome.

Transventricular fenestration of the lamina terminalis: the value of a flexible endoscope: technical note.

BACKGROUND: Recently, the authors demonstrated the technical feasibility of a transventricular translaminar terminalis ventriculostomy with a rigid endoscope. A major problem with this technique remains the contusion of the fornix at the foramen of Monro. Here, the authors evaluated alternative approaches and techniques, including the use of a flexible endoscope. MATERIAL AND METHODS: Feasibility of two approaches-anterior and posterior of the coronal suture-was evaluated on magnetic resonance images and in cadaveric brains. Two different trajectories were selected. Lamina terminalis (LT) fenestration was performed with a rigid and a flexible endoscope using two approaches in 10 fixed cadaver brains. RESULTS: Using the posterior approach 2 cm behind the coronal suture with the two endoscopes caused moderate to severe damage to foramen and fornix. Using the standard approach (Kocher point) with the flexible endoscope avoided damage of these structures. After completion of the anatomical investigation, the authors successfully performed a transventricular fenestration of the LT with the flexible endoscope in one clinical case. CONCLUSION: Rigid scopes provide brilliant optics and safe manipulation with the instruments. However, with the rigid scope, a transventricular opening of the LT is only possible with acceptance of structural damage to the foramen of Monro and the fornix. In contrast, opening of the LT via a transventricular route with preservation of the anatomical structures can be achieved with a flexible steerable endoscope even via a standard burr hole. Thus, if a standard third ventriculostomy is not feasible, endoscopic opening of the LT might represent an alternative, particularly with a flexible scope in experienced hands.

Arachnoid cyst with extraordinary extracranial extension in the skull base as a result of an iatrogenic defect of the middle cranial fossa floor: case report and literature review.

Arachnoid cysts are benign intracranial lesions that are typically diagnosed incidentally. They are divided into two types: congenital and acquired. Acquired arachnoid cysts are rare and usually arise after trauma, infection, or haemorrhage. In this report, a rare case of an iatrogenic multiloculated arachnoid cyst as an unusual complication of a skull base defect is presented. It extended extracranially into the sphenoid sinus, the ethmoid, the infratemporal fossa, the nasopharynx and the nasal cavity, as well as into the pterygomaxillary and retromaxillary space, appearing with a distinct clinical picture. We discuss the differential diagnosis and the potential causes of the lesion and provide a brief review of the literature.

Venous obstruction and jugular valve insufficiency in idiopathic intracranial hypertension.

The pathophysiology of elevated intracranial pressure in idiopathic intracranial hypertension (IIH) is unclear. Cerebral venous outflow obstruction and elevated intracranial venous pressure may play an etiological role. We examined jugular valve insufficiency as a potential factor contributing to intracranial hypertension. Jugular venous valve function was assessed bilaterally by duplex sonography in 20 consecutive patients with diagnosis of IIH and in 20 healthy controls matched for age, gender and body mass index. Diagnosis of valvular insufficiency was based on reflux duration during a controlled Valsalva maneuver. Intracranial venous outflow was evaluated in 11 patients (MR venography in 10, digital subtraction angiography (DSA) in two cases). As a principle result, valvular insufficiency was significantly more frequent in patients with IIH (70 vs. 30%; p < 0.05). This finding was associated with irregular leaflet structures on B-mode imaging (p < 0.01). Bilateral insufficiency was more frequent in the patient group which, however, was not significant (p = 0.08). In addition, sinovenous outflow obstruction was found in five of six patients that had undergone contrast-enhanced MR venography and DSA. The detection rate was inferior in phase-contrast MR imaging (one of five patients). In conclusion, this study gives evidence that valvular insufficiency may play a causal role in IIH. Obesity is a major risk factor for the disease and weight reduction leads to improvement of symptoms. Possibly, increased intra-abdominal pressure is transmitted into the intracranial venous system, causing intracranial hypertension. Jugular valve insufficiency may facilitate pressure transmission. As transverse sinus stenosis was a concomitant finding, these factors may be complementary.