Extensive cerebral invasion of a basal cell carcinoma of the scalp.

Basal cell carcinomas (BCC) are the most common cutaneous malignant neoplasms affecting fair-skinned human beings. They may progressively enlarge and spread by peripheral extension. Intracranial invasion is very rare. A case of a giant BCC of the scalp invading directly into the left hemisphere through the frontal and parietal lobe and meninges is presented. Brain invasion along Virchow-Robin's spaces is demonstrated histopathologically. A review of literature failed to disclose a previous report of similar extensive and fatal cerebral invasion from a basal cell carcinoma of the scalp.

[Magnetic resonance tomography (MRT) in the diagnosis of Failed Back Surgery Syndrome (FBSS)]. / Die Magnetresonanztomographie (MRT) in der Diagnostik des Failed Back Surgery Syndroms (FBSS).

MRT was performed, using a 0.5 and 1.5 Tesla magnet, on 150 patients with FBSS between three days and 23 years following lumbar disc surgery. T1-weighted spin echo sequences were obtained before and after the application of gadolinium (0.15 mmol/kg). In 67 patients the MRT findings were compared with surgical observations. MRT had a sensitivity of 94% in diagnosing recurrent prolapse, a specificity of 100% and accuracy of 94%. The ventral epidural scar tissue, the disc and the neighbouring vertebral bodies showed increased contrast uptake over a prolonged post-operative period.

Prospective documentation and analysis of the pre- and early clinical management in severe head injury in southern Bavaria at a population based level.

Treatment of patients suffering from severe head injury is so far restricted to general procedures, whereas specific pharmacological agents of neuroprotection including hypothermia have not been found to improve the outcome in clinical trials. Albeit effective, symptomatic measures of the preclinical rescue of patients (i.e. stabilization or reestablishment of the circulatory and respiratory system) or of the early clinical care (e.g. prompt diagnosis and treatment of an intracranial space occupying mass, maintenance of a competent circulatory and respiratory system, and others) by and large constitute the current treatment based on considerable organizational and logistical efforts. These and other components of the head injury treatment are certainly worthwhile of a systematic analysis as to their efficacy or remaining deficiencies, respectively. Deficits could be associated with delays of providing preclinical rescue procedures (e.g. until intubation of the patient or administration of fluid). Delays could also be associated in the hospital with the diagnostic establishment of intracranial lesions requiring prompt neurosurgical intervention. By support of the Federal Ministry of Education and Research and under the auspices of the Forschungsverbund Neurotraumatology, University of Munich, a prospective system analysis was carried out on major aspects of the pre- and early clinical management at a population based level in patients with traumatic brain injury. Documentation of pertinent data was made from August 1998 to July 1999 covering a catchment area of Southern Bavaria (5.6 mio inhabitants). Altogether 528 cases identified to suffer from severe head injury (GCS < or = 8 or deteriorating to that level within 48 hrs) were enrolled following admission to the hospital and establishment of the diagnosis. Further, patients dying on the scene or during transport to the hospital were also documented, particularly as to the frequency of severe head injury as underlying cause of mortality. The analysis included also cases with additional peripheral trauma (polytrauma). The efficacy of the logistics and organization of the management was studied by documentation of prognosis-relevant time intervals, as for example until arrival of the rescue squad at the scene of an accident, until intubation and administration of fluid, or upon hospital admission until establishment of the CT-diagnosis and commencement of surgery or transfer to the intensive care unit, respectively. The severity of cases studied in the present analysis is evident from a mortality of far above 40% of cases admitted to the hospital, which was increased by about 20% when including prehospital mortality. The outcome data notwithstanding, the emerging results demonstrate a high efficacy of the pre- and early clinical management, as indicated by a prompt arrival of the rescue squad at the scene, a competent prehospital and early clinical management and care, indicative of a low rate of avoidable complications. It is tentatively concluded on the basis of these findings that the patient prognosis is increasingly determined by the manifestations of primary brain damage vs. the development of secondary complications.

[Continuous measuring of intracranial pressure (ICP) via epidural pressure transducer (author's transl)]. / Kontinuierlich Messung des Hirndrucks mit einem epiduralen Druckaufnehmer.

Continuous epidural monitoring of ICP was performed on 20 patients during a 6 day's period with the model 77450 of Philips. A significant decrease of intracerebral pressure after application of sorbitol and dexamethasone could be demonstrated. Comparing the very low rate of complications with the resulting advantages, the described method can be recommended for controlled treatment of elevated ICP.

[Unilateral exophthalmos and temporary ipsilateral oculomotor paresis and the only symptoms of an extensive chordoma of the base of the skull (author's transl)]. / Einseitiger Exophthalmus und temporäre gleichseitige Okulomotoriusparese als einzige Symptome eines ausgedehnten Chordoms der Schädelbasis.

A case of histologically proved chordoma of the region of the base of the skull in an 18-year-old girl is described. In spite of great extension of the tumor from the clivus into the nasopharynx only a unilateral protrusio bulbi was apparent. The patient was treated with high-dose radiotherapy. Continual half-yearly follow-ups showed during 3 1/2 years no progression of the process.

[Postoperative spondylodiscitis as the cause of failed-back syndrome--clinical aspects, diagnosis, therapy]. / Die postoperative Spondylodiscitis als Ursache des Failed-Back-Syndromes--Klinik, Diagnostik, Therapie.

Postoperative lumbar spondylodiscitis can cause a failed back syndrome. With 0.1 to 3% according to the literature it belongs to the rarer complications following lumbar disc surgery. We present the characteristic clinical picture and typical findings (ESR, plain X-rays, MR) with suspected spondylodiscitis on 19 patients (= 0.2% of 9492 operative interventions for lumbar disc prolapse from 1980 to 1990) and show MR tomography to be the most sensitive investigation. Principles of therapy consist of lumbar immobilisation with a light cast orthesis for an average of 12 weeks and additional antibiotic therapy up to two weeks beyond normalisation of ESR. Finally results of therapy are presented with a satisfying outcome in 84.2% of cases.

[Are sacroiliac joint block and insertion tendinosis of the musculus erector trunici too rarely diagnosis as the etiology of failed back syndrome after intervertebral disk operation]. / ISG-Blockierung und Ansatztendinose des Musculus erector trunici als Ursache des Failed-back-Syndroms nach Bandscheibenoperation--zu selten diagnostiziert?

Dysfunction of sacroiliac joint and tendinosis of erector trunci muscle may cause severe pain after lumbar discectomy. In this paper we discuss pathophysiology, clinical appearance as well as specific diagnostic procedures and therapy. We want to point out that sacroiliac joint dysfunction must be taken into consideration if persistent pain occurs after discectomy.

[Spondylodiscitis following lumbar intervertebral disk surgery. Clinical aspects--diagnosis--therapy]. / Die Spondylodiszitis nach lumbaler Bandscheibenoperation. Klinik--Diagnostik--Therapie.

From 1980 to 1986 6632 operations of the lumbar spine due to disc prolapse were carried out by the Department of Neurosurgery of the hospital of the Technical University of Munich. During this period we saw 14 cases of postoperative spondylodiscitis. Patients' main symptom was increasing low back pain. Physical examination showed difficulty in forward flexion of the body. The blood sedimentation rate was always examined: an average increase to 42/66 mm was recorded. X-ray examination of the lumbar spine and magnetic resonance imaging proved to be the most sensitive methods of investigation, better than scintigram and computed tomography. Our therapeutic management consists of fixation in normal position with a "Light Cast" corset and additional antibiotic therapy with cephadroxil. In comparison to other therapy methods, i.e. restcure, the advantage for our patients is that they can stay at home and move about. Therapy must be continued until the blood sedimentation rate is normal and radiological signs of consolidation can be seen for at least over 10 weeks. Good long-term results were seen in all patients.

The role of magnetic resonance imaging (MRI) in the diagnosis of spondylodiscitis.

Spondylodiscitis is a well-known as well unavoidable complication of lumbar disc surgery. For diagnosis typical clinical symptoms and diagnostic procedures such as x-ray and scintigram are important but MRI proved to be the most sensitive and reliable. However, meaningful results can only be obtained with MRI if the measurement parameters are carefully considered, where by the field strength of the magnet plays a subordinate role. Therapy of spondylodiscitis using a light cast corset is described and it's advantages over other methods are shown.

[Diagnosis of recurrent intervertebral disk prolapse with nuclear magnetic resonance tomography]. / Diagnostik des Bandscheibenrezidivprolaps mittels Kernspintomographie.

Persisting low back pain after lumbar discectomy may have many reasons. Reoperation is likely to be successful if a recurrent disc prolapse is found. The sensitivity and validity of diagnostic tools used cannot as yet be considered to be optimal. For this reason in our study 130 patients who were supposed to have a recurrent disc herniation underwent MRI with and without application of Gadolinium DTPA. In all patients we saw enhancement in the spinal canal. Sensitivity of MRI as verified by reoperation was > 90%. Hence, we can recommend this diagnostic tool for the diagnosis of recurrent disc herniation.

[Recurrent sciatica caused by "conjoined nerve roots". Diagnosis, therapy, follow-up]. / Rezidivierende Ischialgien durch "conjoined nerve roots". Diagnostik, Therapie, Verlauf.

This study reports about 10 patients, with low back pain and sciatica caused by conjoined nerve roots. The described nerve root anomaly could produce sciatica even without the presence of a disc prolaps or another impingement. On computed tomography it is difficult to distinguish conjoined nerve roots from a disc prolaps. Two of these patients have been operated, eight of them have had conservative treatment. Our experiences show that the best results could be achieved with conservative treatment, especially with stabilising gymnastics and with transcutaneous nerve stimulation.

In-vitro resistance of cloned human glioma cells to natural killer activity of allogeneic peripheral lymphocytes.

Cells from an established culture of a human astrocytoma were incubated with normal allogeneic peripheral lymphocytes (PBL) in order to study the natural killer (NK) sensitivity of the in vitro propagated cell line. A proportion of cells in culture formed halos, into which lymphocytes did not penetrate. These cells were successfully cloned and showed a decreased susceptibility to NK cytolysis compared with the parent line. Both cell lines could be transplanted into athymic nude mice. The cloned NK-resistant cells underwent a frequent spontaneous regression in nu/nu mice, despite the fact that when used as targets for nu/nu NK cells in vitro they were only moderately susceptible. Phase-contrast microscopy of the mass-cultured cells co-cultivated with lymphocytes suggested that their morphology and ability to form inpenetrable translucent halos might influence their susceptibility to NK lysis. Experiments performed on this assumption revealed that quiescent and halo forming tumour cells were not the primary targets for NK lysis. Cells in mass culture, although tumorigenic, were thus heterogeneous in respect of susceptibility to NK attack. These findings might be relevant to the mechanism of immune escape and tumour heterogeneity in respect of spontaneous cell-mediated lysis.

[Thoracic intervertebral disk displacement: a rare differential diagnosis of segmental irritation--guidelines for use of chiropractic therapy]. / Der thorakale Bandscheibenvorfall: eine seltene Differentialdiagnose der segmentalen Irritation--Richtlinien zur Anwendung von Chirotherapie.

Thoracic disc herniations rarely occur; they vary with respect to the clinical symptomatic and do not always lead to neurological deficit. A patient is being reported on with first symptoms of unspecific back pain. The patient has been frequently treated within 12 months (at regular intervals) exclusively by chiropractic manipulation without a considerable success. It is the objective of this case report that in persistent and therapy resistant back pain without obvious neurological deficite beside native radiographs further diagnostic investigation (MRI) is indicated. Concerning chiropractic manipulations (mobilisation techniques with impulse) this paper recommends testing maneuvers, the consideration of contraindications (structural lesions, neurological deficite) and emphasizes the use of atraumatic manipulation techniques.

[Ependymoma of the thoracic spine. Cervico-brachialgia as the first symptom--a case report]. / Das Ependymom der Brustwirbelsäule. Die Zervikobrachialgie als Erstsymptom--eine Kasuistik.

Most frequently the ependymomas of the central nervous system affect the Conus medullaris and Filum terminale. Ependymomas of the thoracic spine with association of a tumor-caused syringomyelia are extremely rare. The reported 50 years old patient with a thoracic ependymoma realized first symptoms as a shoulder-arm pain caused by the tumor-syrinx. The case report indicates that MRI is the superior imaging modality for primary tumors of the central nervous system. All relevant diagnostic and therapeutic informations derived from the MRI. The article describes the clinical manifestations, the diagnostic way and therapeutic procedure in the problem region thoracic spine.

Dorsal extradural lipoma as cause of spinal claudication. Case report and review of the literature.

Extradural spinal lipomas are rare tumorous lesions. "True adult lipomas" have to be histologically differentiated from angiolipomas. The authors describe a case of segmental dorsal lipomas in the lower lumbar spine which led to a clinical apparent spinal claudication. Having reviewed the literature this case is the first ever described. In this case MRI was the diagnostic tool of choice. The tumor could be removed completely via interarcual laminotomy and flavectomy. The clinical outcome was excellent. In differential diagnosis of a spinal claudication this rare cause should be kept in mind when typical osseous changes are absent.

[Perioperative cytostatic treatment of malignant supratentorial brain tumors with BCNU with special reference to tumor site]. / Perioperative cytostatische Behandlung supratentorieller maligner Hirntumoren mit BCNU unter spezieller Berücksichtigung der Tumorlage.

During the period from 1979 until 1986, sixty male and female patients were treated perioperatively in the Neurosurgical Department of the Surgical Clinic and OPD of the Munich Technical University with the alkylating agent BCNU. Up to five treatment cycles were employed, the first treatment cycle being initiated pre-operatively. In none of the cases were disorders of wound healing seen. Among these sixty patients there was one case of suspected BCNU lung and one case of massive leukopenia. Considering the rate of complications described in the international literature, this figure is extremely small. As to the study of the mean survival time, only 30 patients presenting supratentorial malignant tumours of comparable localisation were included. In light of these strict criteria the perioperative BCNU treatment at our clinic resulted in a mean survival time of 67.1 weeks which in comparison with the literature can be regarded as a good result. We would therefore only recommend cytostatic treatment with peroperative administration of BCNU.

Prophylaxis of postoperative lumbar spondylodiscitis.

Spondylodiscitis after lumbar disc surgery is a well-known complication with a frequency of 0.1 to 3%. According to the authors, the etiological factors are: combination of operated segment instability, damage to the lower and upper plates due to disc space curettage and transmission of germs. After treatment of 100 selected cases, all with increased risk of postoperative spondylodiscitis, distinct possibilities for prevention have been discovered. Basic treatment consisted of 3 x 80 mg perioperative doses of Gentamicin i.m. In addition a collagen sponge (Sulmycin Implant) containing 50 mg Gentamycin was inserted in the cleared disc spaces of 50 patients. Complications in this procedure were not observed. The following is recommended for prevention of postoperative spondylodiscitis: a careful operating technique, perioperative antibiotics, and in particularly endangered patients, insertion of Sulmycin Implant in the disc-spaces.

Optimized visualization of contrast medium dependent differences in CT/MRI scans by RGB transformation.

OBJECTIVE: In order to be able to assess the contrast medium enhancement of vessels and regions with disturbed blood-brain barrier, the neurosurgeon must mentally perform a subtraction of the corresponding native and contrast-enhanced scans of the CT or MRI. The principle disadvantages of this comparison are the amount of time required and the potential errors which may result from false interpretation. METHODS: The process presented here combines corresponding scans without and with contrast medium offline on a PC. In this process each couple of the black and white scans is assigned to the colour channels of the RGB system (red, green, blue) and transformed to one colour picture of the RGB colour space (additive colour mixture). RESULTS: We demonstrate that contrast medium-dependent changes can be represented in a colour contrast of complementary colours in one single picture. Additionally, the unchanged structures remain in the black and white contrast as they were before. CONCLUSION: Thanks to the optimized visualization of contrast medium dependent differences there are besides saving in time further advantages such as the reduced amount of pictures and an objective representation.

[Non-surgical management of an infected ventriculo-atrial shunt]. / Nicht-operative Sanierung eines infizierten ventrikulo-atrialen Shunts.

We report on a 81-year old patient who showed clinical signs of a shunt infection eight months after implantation of a ventriculo-atrial shunt system Heyer-Schulte. The reason was identified to be a massive infection with staphylococcus albus. Elimination of the infection was achieved by intravenous administration of fosfomycine and local instillation of gentamycin into the valve. The follow-up was uneventful for more than two years until the death of the patient in January 1987.

The value of spinal magnetic resonance imaging (MRI) in locating prolapses of lumbar intervertebral discs.

Between 1986 and 1988 100 patients in whom MRI had been used to diagnose prolapses of lumbar intervertebral discs were admitted to the neurosurgical department of the Munich Technical University. MRI proved to be a valuable diagnostic technique, even if one has to concede certain limitations to the usefulness of the results when compared to conventional methods, particularly in such cases where clinical symptoms are not clear. Typical findings are illustrated and compared with those seen in MRI, whose relative importance is discussed.