Assessment of cerebral blood flow during infusion test in the diagnosis of normal pressure hydrocephalus.

BACKGROUND: Many studies indicate that the increase in intracranial pressure (ICP) leads to cerebral blood flow velocity (CBFV) changes. This relationship was accurately determined in patients with traumatic brain injury, OBJECTIVES: The aim of this study was to determine how the changes in intracranial pressure induced during an infusion test influence cerebral blood flow. MATERIAL AND METHODS: 40 patients with enlarged ventricular systems (Evan's ratio > 30%) who underwent a diagnostic lumbar infusion test (LIT) were included. Tests were performed at the Department of Neurosurgery, Wroclaw Medical University. CBFV in the middle cerebral artery was measured using transcranial Doppler (TCD) simultaneously during the standard lumbar infusion test. TCD measurements were continued with simultaneous recording of CSF pressure with a frequency of 100Hz. A total number of 5800 measurements (10-second periods) performed during the three phases of the infusion test (stable, infusion and decrease) was obtained. RESULTS: In the stable phase of LIT, a weak positive correlation between ICP and mean CBFV (R = 0.193, p < 0.01) was observed. There was no statistically significant correlation between ICP and the pulsatility index (PI, Gosling Index). During the increased-ICP phase of LIT (infusion, decrease), we observed significant changes in CBFV expressed by a decrease of diastolic velocity and an increase of systolic velocity. A simultaneous increase of pulsation correlated with an increase in ICP (R = 0.371, p < 0.01). There were no significant changes in mean CBFV. CONCLUSIONS: In patients with ventriculomegaly, the mean cerebral blood flow is maintained despite a significant increase in ICP, within the limits of the infusion test. It is noted the relative increase of the pulsatility indices of CBF may indicate preserved cerebrovascular reactivity.

Early cerebral hemodynamic alternations in patients operated on the first, second and third day after aneurysmal subarachnoid hemorrhage.

Surgery timing after aneurysmal subarachnoid hemorrhage (SAH) may influence the risk of vasospasm after early surgical procedure and is correlated with SAH extensiveness. A group consisting of 127 patients with aneurysmal SAH was studied. The changes of mean flow velocity (MFV) were measured in middle cerebral artery (MCA) and in anterior cerebral artery (ACA) by transcranial Doppler sonography (TCD) in three groups of patients divided according to the surgery timing (on the first, second and third day after SAH). Changes of MFV values in MCA and in ACA were similar in all groups. MFV values in the group of patients operated on the third day were the lowest and the pathologic values lasted for the shortest time. In patients with massive SAH (Fisher IV group) and mild SAH (Fisher II group), the lowest MFV values were observed, if patients were operated within 24 hours after SAH. In patients without SAH (Fisher I group), the MFV values were the lowest, if they were operated on the third day after SAH. In patients with severe SAH (Fisher III group), the lowest risk of vasospasm was observed, if they were operated on the second day after SAH; however, the highest risk was found in patients operated on the first day after SAH. Our study suggests: (1) in patients with severe SAH operated on the second day, the lowest risk of vasospasm was observed, and the highest risk of vasospasm was observed if those were operated on the first day; (2) the highest risk of vasospasm was observed in patients operated within 24 hours with mild and massive SAH and in patients without SAH operated on the third day after SAH.

[Analysis of expression of estrogen (ER) and progesterone receptors (PR) in brain glial tumors and its correlation with expression of p53 protein and proliferating cell nuclear antigen (PCNA)]. / Analiza wystepowania receptorów progesteronowych (PR) i estrogenowych (ER) w glejakach mózgu i ich zaleznosc od ekspresji bialka p53 i jadrowego antygenu proliferacyjnego (PCNA).

BACKGROUND AND PURPOSE: All the types of the glial cells contain estrogen (ER) and progesterone receptors (PR) but their occurrence in glial tumors of the brain is still controversial. The aim of this research was the clinical analysis of ER and PR expression in correlation with histological malignancy and expression of p53 and PCNA. MATERIAL AND METHODS: The investigation was carried out on a group of 56 patients operated on at the Neurosurgical Department of Wroclaw Medical University. The percentage of tumors containing ER and PR was assessed and mean receptor expressions were compared. Classical histological tests, immunohistochemical tests for ER, PR, p53 and PCNA with monoclonal antibodies (DACO) were performed for every specimen of tumor tissue. RESULTS: ER occurred in 24 cases (42.9%), PR in 10 cases (17.9%). 49% of highly malignant gliomas (WHO III and IV) were ER positive, whereas 29% of tumors grade I and II were ER positive. Frequencies of PR positive tumors were similar in both groups. Mean PR expression in p53 positive group was 8% and in p53 negative group 1.5% (p=0.017). Mean ER expression in PCNA positive group was 7.4%, whereas in PCNA negative group 2.7% (p<0.01). CONCLUSIONS: Frequency of ER occurrence is higher in highly malignant tumors. ER expression is correlated with proliferative activity (PCNA). PR expression is positively correlated with intensity of mutant p53 protein.

[Analysis of PCNA, Ki67, AgNOR and p53 expression in brain glial tumors]. / Analiza ekspresji antygenów proliferacyjnych (PCNA, Ki67), regionów organizatorów jaderkowych (AgNOR) i bialka p53 w nowotworach glejowych mózgu.

BACKGROUND AND PURPOSE: The aim of this study was to evaluate clinical usefulness of proliferating cell nuclear antigen (PCNA), Ki67 antigen, p53 protein and silver-binding nucleolar organizer regions (AgNOR) in brain glial tumors. MATERIAL AND METHODS: The investigation of PCNA, Ki67 and p53 was carried out on a group of 120 patients with glial tumors operated on at the Neurosurgical Department of Wroclaw Medical University including 63 patients operated again because of recurrence. AgNOR was evaluated on a group of 64 patients including 38 patients operated again. Classical histological tests, immunohistochemical tests for PCNA, p53 and Ki67 activity with monoclonal antibodies (DACO) and histochemical tests for AgNOR were performed on every specimen of tumor tissue. The level of 40% for PCNA, 2.75 (equal to median) for AgNOR and 5% for Ki67 and p53 was adopted as significant. RESULTS: Mean expression of PCNA of glial tumors grade I and II was 32%, grade III and IV - 44% (p<0.05). Mean expression of AgNOR was 1.88 and 3.16 (p=0.00001), respectively. Average PCNA expression in recurrent tumors to 12 months was 52.7% and for later recurrences - 35.4% (p<0.05). Average expressions of AgNOR were 3.38 and 2.68 (p<0.05), respectively. Differences of Ki67 and p53 expressions were not significant. CONCLUSIONS: PCNA and AgNOR expressions correlate with proliferative activity, growth rate and histological malignancy, reaching high values in highly malignant and early recurrent tumors. Antigens Ki67 and p53 do not seem to be predictive markers of glial tumors.

The relation between cerebral blood flow velocities as measured by TCD and the incidence of delayed ischemic deficits. A prospective study after subarachnoid hemorrhage.

Patients (n = 127) with aneurysmal subarachnoid hemorrhage (SAH) were examined by transcranial Doppler ultrasonography (TCD) in a prospective study to follow the time course of the posthemorrhagic blood flow velocity in both the middle cerebral artery (MCA) and in the anterior cerebral artery (ACA). Results were analysed to reveal their relationship and predictive use with respect to the occurrence of delayed ischemic deficits. Mean flow velocities (MFV) higher than 120 cm sec(-1) in MCA and 90 cm sec(-1) in ACA were interpreted as indicative for significant vasospasm. In 20 of our 127 patients (16%) a delayed ischemic deficit (DID) was subsequently diagnosed clinically (DID+ group). Patients in the DID+ group can be characterized as those individuals who presented early during the observation period post-SAH with highest values of MFV, a faster increase and longer persistence of pathologically elevated MFV-values (exceeding 120 cm sec(-1) in MCA and 90 cm sec(-1) in ACA). They also show a greater difference in MFV-values if one compares the operated to the nonoperated side. Differences in MFV-values obtained in MCA or ACA were statistically significant (p < 0.05) for DID+ and DID- patients. The daily maximal increase of MFV was found between days 9 and 11 after SAH. In the DID+ group, the maximal MFV was 181 +/- 26 cm sec(-1) in MCA and 119 +/- 14 cm sec(-1) in ACA. In contrast to this, patients in the DID- group were found to present with MFV of 138 +/- 11 cm sec(-1) in MCA and 100 +/- 7 cm sec(-1) in ACA respectively. Delayed ischemic deficits appeared three times more often in DID+ patients than in patients with MFV < 120 cm sec(-1), if they showed a MFV > 120 cm sec(-1) in MCA. If pathological values were obtained in ACA, this ratio increases to about four times, if DID + patients presented with MFV > 90 cm sec(-1) versus patients with MFV < 90 cm sec(-1). Daily monitoring of vasospasm using TCD examination is thus helpful to identify patients at high risk for delayed ischemic deficits. This should allow us to implement further preventive treatment regimens.