Resection plus whole-brain irradiation versus resection plus whole-brain irradiation plus boost for the treatment of single brain metastasis.

BACKGROUND: The optimal treatment for patients with a single brain metastasis is controversial. This study investigated the value of a radiation boost given in addition to neurosurgerical resection and whole-brain irradiation (WBI). PATIENTS AND METHODS: In this retrospective study, outcome data of 105 patients with a single brain metastasis receiving metastatic surgery plus WBI (S + WBI) were compared to 90 patients receiving the same treatment plus a boost to the metastatic site (S + WBI + B). The outcomes that were compared included local control of the resected metastasis (LC) and overall survival (OS). In addition to the treatment regimen, eight potential prognostic factors were evaluated including age, gender, performance status, extent of metastatic resection, primary tumor type, extracerebral metastases, recursive partitioning analysis (RPA) class, and interval from first diagnosis of cancer to metastatic surgery. RESULTS: The LC rates at 1 year, 2 years, and 3 years were 38%, 20%, and 9%, respectively, after S + WBI, and 67%, 51%, and 33%, respectively, after S + WBI + B (p = 0.002). The OS rates at 1 year, 2 years, and 3 years were 52%, 25%, and 19%, respectively, after S + WBI, and 60%, 40%, and 26%, respectively, after S + WBI + B (p = 0.11). On multivariate analyses, improved LC was significantly associated with OP + WBI + B (p = 0.006) and total resection of the metastasis (p = 0.014). Improved OS was significantly associated with age ≤ 60 years (p = 0.028), Karnofsky Performance Score > 70 (p = 0.015), breast cancer (p = 0.041), RPA class 1 (p = 0.012), and almost with the absence of extracerebral metastases (p = 0.05). CONCLUSION: A boost in addition to WBI significantly improved LC but not OS following resection of a single brain metastasis.

[Brachytherapy in combination with function-preserving surgery. An interdisciplinary challenge]. / Brachytherapie in Kombination mit zurückhaltender Chirurgie. Eine interdisziplinäre Herausforderung mit dem Ziel des Organerhalts.

A multimodal, interdisciplinary approach known as intensity-modified brachytherapy is a promising alternative for patients with advanced head and neck cancer infiltrating the orbita and skull base. An 87-year-old man presented with a recurrence of squamous cell carcinoma of the medial corner of the left eye that had been locally resected and irradiated by external beam radiotherapy multiple times. The cancer was resected with preservation of the eye with close margins, implantation of afterloading catheters, and reconstruction of the defect with a median forehead flap. The patient was irradiated with a total radiation dose of 30 Gy IMBT. After 1 year, there was no evidence of locoregional recurrence. The background of this therapeutic process and analysis of the current literature regarding this interdisciplinary treatment of head and neck cancer infiltrating the orbita and skull base are discussed based on this case report.

Clinical biochemical tissue monitoring during ischaemia and reperfusion in major vascular surgery.

BACKGROUND: Major vascular surgery with aortic cross-clamping is associated with temporary ischaemia of the lower limb due to lack of tissue blood flow. The present study was designed to determine if the short-term changes in cellular metabolism occurring during this situation can be detected by subcutaneous microdialysis. It was also hoped to ascertain if this new technique is useful in the continuous bedside monitoring of metabolism during aortic surgery. METHODS: In a controlled clinical study 20 patients undergoing elective aortic surgery were monitored using microdialysis probes that were inserted in the subcutaneous tissue of the left lower limb and a non-ischaemic region (shoulder). Interstitial fluid was obtained and the concentrations of glucose and lactate during lower limb ischaemia and during reperfusion were measured and compared with concentrations observed in fluid obtained from the non-ischaemic control tissue. RESULTS: Circulatory occlusion caused an immediate and significant decrease in the glucose/lactate ratio from 3.1+/-1.3 to 0.48+/-0.5 (P<0.05) that returned to preocclusion values within 2 h of commencing reperfusion. CONCLUSION: We suggest that microdialysis may be used both to assess acute changes in tissue metabolism during ischaemic periods and also to act as an additional tool for the detection of peri-operative acute variations in limb blood flow.

Dural arteriovenous malformation in the anterior cranial fossa.

Two cases of dural arteriovenous malformation (AVM) at the base of the anterior cranial fossa are described. In both cases an intracerebral hematoma following the rupture of the AVM was the first indication of the disease. In one case, the malformation was supplied both by the anterior ethmoidal artery and frontopolar artery draining into the superior sagittal sinus. In the second case, the right anterior ethmoidal artery with draining veins into the superior sagittal sinus and sphenoparietal sinus was the feeding vessel. Surgical evacuation of the hematoma and excision of the malformation was performed on both patients. The typical clinical signs and radiological findings are described. A review of the pertinent literature is given.

Hydrocephalus therapy: reduction of shunt occlusions using a peel-away sheath.

In order to avoid shunt occlusions through particles of brain parenchyma a new procedure was used. Conventionally during ventricle puncture brain tissue may intrude into perforating holes of the ventricular catheter and subsequently shunt dysfunction may occur. By using a peel-away sheath the ventricular catheter can be protected during puncture. The conventional technique (n=90) was compared with the peel-away sheath technique (n=20) in a retrospective analyses in regard to shunt revisions during a 1-year period. Shunt revision was done in 18% (16/90) within 1 year using the conventional technique, respectively, 5% (1/20) using the peel-away sheath technique. Although criteria for statistical significance were not reached these data are worth to be mentioned. A randomised prospective study is initiated and the key features are presented.

Cavernous angioma as a rare neuroradiologic finding in the cavernous sinus.

We report the case of a 56-year-old female with a pathologically confirmed cavernous angioma of the cavernous sinus. There are only a few reports on cavernous sinus angiomas in the literature. In contrast to typical intracerebral cavernous angiomas, these lesions are characterized by strong contrast enhancement on computed tomography and magnetic resonance imaging. In spite of the problematic location within the cavernous sinus, these angiomas can be completely resected without additional neurologic deficits. The clinical course of the patient and the unusual neuroradiologic imaging findings, as well as the cases from the literature are discussed.

HELLP syndrome with haemaglobin vasospasm.

The syndrome of haemolysis, elevated liver enzymes and low platelets (HELLP syndrome) is a life threatening, severe complication of pre-eclampsia with typical laboratory findings. An unusual case of a 36-year-old woman with HELLP syndrome and the initial complication of intracerebral haemorrhage is presented. The diagnosis of HELLP syndrome was confirmed by elevated liver enzymes, low platelets, increased total bilirubin and increased lactate dehydrogenase. The intracranial haematoma was removed with good neurological recovery ensuing. However, this case was complicated by cerebral vasospasm on the eleventh day, confirmed by cerebral angiography and computer tomographic findings. The patient died from brain swelling. Possible vasospam should be considered during the treatment of patients with HELLP syndrome.

[Microdialysis for metabolic monitoring during septicemia]. / Mikrodialyse als Stoffwechselmonitoring während der Septikämie.

Currently, metabolic changes in ICU patients in critical states are determined mainly by indirect laboratory parameters (e.g. blood lactate). Microdialysis is a new means of performing metabolic monitoring that permits organ-specific objectification on the basis of interstitial fluid samples. Continuous endotoxin infusion was administered to 10 female pigs and, in addition to hemodynamic monitoring, lactate and glycerol in the subcutaneous, intramuscular and hepatic tissue were measured by microdialysis. The interstitial concentrations of lactate and glycerol rose significantly under endotoxaemia and showed an earlier increase than blood lactate levels. Microdialysis is simple to apply, appears to be a suitable means of obtaining important information about cellular metabolic changes in different tissues of the critically ill patient, and can detect subtle changes that laboratory parameters can identify only later and incompletely.

[Deep brain stimulation in the posterior hypothalamus for chronic cluster headache. Case report and review of the literature]. / Tiefenhirnstimulation im posterioren Hypothalamus zur Behandlung des chronischen Clusterkopfschmerzes. Fallbericht und Literaturübersicht.

Primary chronic cluster headache (CCH) is a rare but severe pain syndrome and pathophysiological explanations are still missing. PET studies revealed activation in the hypothalamus and therefore it became a target for therapeutic deep brain stimulation (DBS). A case of a 39-year-old woman and a literature review are presented. The patient suffered from left-sided primary CCH for 14 months. The headache was resistant to any pharmacological therapy or treatment was limited by major drug side effects. Using a stereotactic approach a quadripolar lead was inserted in the left posterior hypothalamus. A test trial was performed and attack frequency, intensity, and adverse events were noted. Intraoperative test stimulation evoked typical side effects like tachycardia, diplopia and panic attacks. During the trial test a marked reduction in frequency and intensity of CCH was recorded. After 7 days the stimulation device was implanted subcutaneously. DBS with implantation of a lead in the ipsilateral inferior posterior hypothalamus is an experimental treatment option and should be offered to selected patients in a prospective controlled clinical trial. Data concerning the long-term follow-up need to be collected.

Outcome prediction of third ventriculostomy: a proposed hydrocephalus grading system.

An important factor in making a recommendation for different treatment modalities in hydrocephalus patients (VP shunt versus endoscopic third ventriculostomy) is the definition of the underlying pathology which determines the prognosis/outcome of the surgical procedure. Third ventriculostomies (3rd VS) are successful mainly in obstructive hydrocephalus but also in some subtypes of communicating hydrocephalus. A simple, easily applicable grading system that is designed to predict the outcome of 3rd VS is proposed. The hydrocephalus is graded on the basis of the extent of downward bulging of the floor of the third ventricle, which reflects the pressure gradient between the 3rd ventricle and the basal cisterns, presence of directly visualised CSF pathway obstruction in MRI, and the progression of the clinical symptoms resulting in five different grades. In this proposed grading system, grade 1 hydrocephalus subtype shows no downward bulged floor of the 3rd ventricle, no obstruction of the CSF pathway, and no progressive symptoms of hydrocephalus. There is no indication for 3rd VS. Grades 2 to 4 show different combinations of the described parameters. Grade 5 subtype shows a markedly downward bulged floor of the 3rd ventricle and direct detection of the CSF pathway obstruction (i.e., aqueductal stenosis) with progressive clinical deterioration. Retrospective application of this grading scheme to a series of 72 3rd VS has demonstrated a high correlation with the outcome: The success rate in grade 3 reached 40%, in grade 4: 58%, and in grade 5: 95%. This standardised grading system predicts the outcome of 3rd VS and helps in decision making for 3rd VS versus VP shunting.

Extraventricular intracisternal obstructive hydrocephalus--a hypothesis to explain successful 3rd ventriculostomy in communicating hydrocephalus.

The basis of successful 3rd ventriculostomy in cases of communicating hydrocephalus is not yet understood. We performed 3rd ventriculostomies in 5 patients with free cerebrospinal fluid (CSF) communication from the ventricles to the cisterna magna. Preoperative magnetic resonance images (MRIs) showed dilated ventricles, a downward bulging floor of the 3rd ventricle (interpreted as a sign of pressure gradient between the ventricles and basal cisterns) and a free communication to an enlarged cisterna magna. The other basal cisterns were of normal or smaller size. All patients recovered from their clinical symptoms and none of them needed a shunt. The hypothesis of an intracisternal CSF pathway obstruction (e.g. between the cisterna magna and the prepontine cistern) could explain the MRI findings, although such an obstruction cannot be directly visualized. It would also explain the successful 3rd ventriculostomies in these cases.

Asymmetric hydrocephalus: safe endoscopic perforation of septum pellucidum: technical note.

Asymmetric and/or loculated hydrocephalus can be treated with endoscopic septum fenestration to avoid or to simplify a shunt (1,2). In asymmetric lateral ventricles the septum pellucidum is dislocated to the opposite side and may even be in contact with the lateral wall of the contralateral ventricle (i.e., the thalamus). Perforating the septum with a catheter or a laser beam may damage the underlying tissue. The authors show a safe perforation technique: the septum is pulled towards the tip of the endoscope to enlarge the underlying space. Now the catheter can perforate the septum without the risk of damage to the underlying tissue.

The mechanism of fornix lesions in 3rd ventriculostomy.

Fornix lesions as a complication of 3rd ventriculostomy are rare and almost not reported. However, in our series of 94 procedures we observed 5 fornix lesions. Although we did not find any clinical deterioration, we were alarmed by these unexpected incidences and analysed the mechanism. All fornix lesions occurred using an endoscope sheath with separated channels for the endoscope itself, the instruments and for rinsing and suction. The limited field of view suggests the surgeon to be already inside the 3rd ventricle while the tip of the scope is still in the lateral ventricle just before the foramen of Monro. The instrument enters the optic field--depending on the used optic--as lately as 2 to 3 mm. The analysis showed that the lesions happened when the instruments were in the blind angle of the endoscope's optic which itself was outside of the foramen of Monro. Being aware of this mechanism with its potential risks it did not occurred again.

Pro and cons of different designs of rigid endoscopes.

Experience with more than 200 neuroendoscopic procedures taught us the advantages and disadvantages of the different endoscope designs. Using an endoscope with a sheath with separate channels for the endoscope, the instruments as well as for rinsing and suction we found advantages in rinsing properties, handling, and preciseness of instrument steering. On the other hand an endoscope with a sheath with a singular channel for the endoscope itself, the instruments, rinsing, and suction the advantages were better in visualization of the instruments, more available instruments, and easier extraction of larger specimen. The knowledge of these advantages makes it possible to select the adequate endoscope regarding its design, especially in more complicated cases.

[Main symptom: "pulse-synchronous tinnitus"]. / Hauptsymptom: "Pulssynchrones Ohrgeräusch".

BACKGROUND: In comparison to cochlear or nerval generated ear noises, pulsatile tinnitus is a rare condition. Due to its own etiology, specific diagnostic steps are necessary. PATIENTS: We present 6 patients with pulsating tinnitus as the leading symptom. By means of these cases the various etiologies, rational diagnosis and therapy will be discussed. RESULTS: Pulsatile tinnitus is frequently caused by an increased blood flow in the cranial vessels through various pathologies. Besides those diseases going along with a general increase of blood circulation, regional alterations can be classified as hypervascular/hyperemic, arterial or venous conditioned. CONCLUSIONS: Physical examination and modern imaging can detect the underlying reasons in a quick and reliable way.

How to perforate safely a resistant floor of the 3rd ventricle? Technical note.

Third ventriculostomy for acquired non-communicating hydrocephalus is an excellent alternative to shunting procedures. Nevertheless, complications can be severe and even fatal (e.g., lesion of the basilar artery), especially if the floor of the 3rd ventricle is very tough and/or opaque. The authors describe a safe method of sharp perforation of the floor, which should be applied if blunt fenestration cannot be achieved easily.

Pituitary apoplexy after cardiac surgery presenting as deep coma with dilated pupils.

Acute clinical deterioration due to infarction or haemorrhage of an existing, often previously unrecognized, pituitary tumour is a rare but well-described complication. It can occur spontaneously or may be caused e.g. by mechanical ventilation, infection or surgical procedures. We report on a case of pituitary apoplexy occurring in a 64-year-old patient 3 weeks after cardiac surgery. The patient presented with deep coma and dilated pupils. Magnetic resonance imaging revealed a haemorrhagic pituitary tumour. After prompt endocrinologic replacement therapy with levothyroxine and hydrocortisone the patient regained consciousness. Neurological examination revealed right oculomotor nerve palsy and bilateral cranial nerve VI palsy. Subsequent trans-sphenoidal removal of a nonfunctional macroadenoma with large necrotic areas was performed. The patient recovered completely. To our knowledge, pituitary tumours presenting with a combination of deep coma and dilated pupils must be considered exceedingly rare. Possible pathophysiologic mechanisms are discussed. As our case illustrates, even in severe cases complete recovery is possible if the diagnosis is suspected, and diagnostic and therapeutic measures are initiated in time.

Twenty colloid cysts--comparison of endoscopic and microsurgical management.

The management of colloid cyst remains controversial, evaluation of the competing methods seems to be necessary. We report on our experience with colloid cysts in the last decade: ten were managed solely endoscopically, 10 were resected microsurgically (9 via a transcortical/transventricular, 1 via a transcallosal approach). The outcome in the endoscopic group was excellent in 9 cases and unsatisfying in 1 case (recurrence). In the microsurgical group we achieved a good outcome in 5 of 10 cases, a fair outcome in 4 cases and 1 lethal outcome (caused by pulmonary embolism). Complications in the endoscopic group: one intraoperative bleeding, 1 stitch granuloma, 1 mispuncture of the ventricle, and 1 meningitis. Complications in the microsurgical group: 1 subdural effusion, 1 flap infection, 1 mild hemiparesis, 1 transient impairment of consciousness and 1 pulmonary embolism. Mean operative time and length of hospitalization of the endoscopic group were clearly shorter than in the microsurgical group: 91 min versus 267 min time of surgery, 5.1 days versus 18.9 days of hospitalization. Complete resection was achieved in 8 of 10 cases of microsurgery, and in 3 of 10 cases in endoscopy. Endoscopic management results in lower costs and superior patients' comfort. The reduced number of total resections in the endoscopic group may lead to a higher recurrence rate in long-term follow-up, which might be a serious disadvantage of endoscopy. However, more experience in the endoscopic techniques may result in a higher rate of total resection of colloid cysts.

[Continuous biochemical tissue monitoring during acute hypoxia]. / Kontinuierliche Uberwachung des Gewebsstoffwechsels während der akuten Hypoxie.

Oxygen deficiency during critical illness is known to cause profound changes in cellular metabolism with subsequent organ dysfunction. Clinical treatment in these patients is focussed on rapid reoxygenation to avoid a prolonged impaired synthesis of cellular high-energy phosphates (ATP). The effect of this therapeutical intervention on the level of the cell, however, has not yet been objectivized. The aim of the present experimental study was to biochemically monitor different tissues during hypoxia and reoxygenation using in vivo microdialysis. Eighteen adult male CD-rats (412-469 g; Ivanovas, Kisslegg, Germany) were normoventilated under general anaesthesia (FiO2 = 0.21). Ten were then subjected to a period of hypoxia (FiO2 = 0.1, 40 min) and reoxygenated with FiO2 = 0.21, while eight control animals were continuously ventilated with FiO2 = 0.21. In addition to invasive haemodynamic monitoring, biochemical tissue monitoring was performed using CMA 20 microdialysis probes, which were inserted into the muscle (m), subcutaneous space (s), liver (l) and peritoneal cave (p) with semicontinuous analyses of lactate and pyruvate at intervals of 15 minutes. Hypoxia induced a significant decrease in mean arterial pressure compared to the control group (p < 0.05). At the same time significant increases in blood lactate (12.3 + 4.1 mmol/l (hypoxia) vs. 1.5 +/- 0.3 mmol/l (control); p < 0.05) and in negative base excess (17.3 + 7 mmol/l (hypoxia) vs. 2.6 + 1.8 mmol/l (control), p < 0.05) occurred. Compared to unchanged levels in the control animals, the interstitital lacate/pyruvate ratio in the investigation group rose to significantly higher values (455 + 199% of baseline (m), 468 + 148% (p), 770 + 218% (l) and 855 + 432% (s) (p < 0.05). An immediate return to the baseline values after the start of reoxygenation was noted in the L/P ratio during the observation period. Using microdialysis, it was possible to objectify the effect of oxygen deficiency and restoration on tissue metabolism. Regarding clinical and preclinical practice, microdialysis monitoring should be performed to include biochemical cellular effects as an additional target for therapeutical interventions.

A new technique for attaching a stereotactic frame to the head: technical note.

The aim of this study was to develop a device which allows an intermediate, painless fixation of a stereotactic frame prior to definite pin fixation. To stabilize the stereotactic frame rubber coated metal springs were used. By testing the springs on 30 volunteers with different head diameters and circumferences the optimal shape was determined. In the clinical setting 15 patients undergoing stereotactic surgery were tested, stability and patient's convenience were measured. The procedure was well tolerated and measurements revealed symmetric distances between head and frame. Therefore these metal springs are a useful accessory to the Leksell stereotactic system.