Pregnancy-related primary brain and spinal tumors.

We reviewed the literature concerning primary brain and spinal tumors with first manifestation or acceleration of symptoms during pregnancy or within the first postpartum week and encountered four new cases in our center. The incidence of brain tumors that become symptomatic during pregnancy appears to be decreased compared with that in age-matched women. The relative frequency of the different primary brain tumor types is not changed by pregnancy. The number of meningiomas gradually tends to increase during pregnancy, with gliomas and spinal vascular tumors accumulating in the first and third trimesters, respectively. Postpartum amelioration of symptoms has especially been described for meningiomas and spinal vascular tumors. We conclude that different types of tumors are influenced at different stages of pregnancy. Although progesterone receptors predominate compared with estrogen receptors, no definite causal relationship with progesterone has been established.

Hypofractionated radiation therapy in patients with glioblastoma multiforme: results of treatment and impact of prognostic factors.

PURPOSE: Median survival of patients with glioblastoma multiforme (GBM) is only about 4 months with surgery and about 9 months for surgery followed by radiotherapy. Prolonged treatment is futile for many patients and the time of treatment and hospitalization should be minimized. METHODS AND MATERIALS: This was a prospective, nonrandomized study of 30 patients treated with a hypofractionated radiation scheme (42 Gy in 14 fractions). RESULTS: Median survival was 36 weeks. Age, Karnofsky performance status (KPS) and extent of surgery were strongly interrelated and all correlated with survival (p < 0.05). Three prognostic groups were identified. Patients with three favorable prognostic factors (age <50, KPS 80-100, and > or = 75% of the tumor removed) had the best prognosis (median survival 50 weeks). Patients with no favorable prognostic factors (age > or = 50, KPS < or = 70, and < 75% of the tumor removed) had the worst prognosis (median survival 25 weeks). Median survival of the intermediate group (with one or two favorable prognostic factors) was 38 weeks. No severe acute or late toxicity was observed. CONCLUSION: The treatment results are comparable to those achieved with conventional radiotherapy schemes. Based on the number of favorable prognostic factors (age < 50, KPS 80-100 and > or = 75% of tumor resected) the radiation schedule should be selected.

Elective trepanation for acute epidural hematoma by Dr. Nicolaes Tulp (1593-1674).

The improved knowledge of human anatomy in the 16th century led to an increase in the practice of cranial trepanation in clinical cases, and detailed definitions of indications for performing this operation were provided by several authors. It was not until the 18th century, however, that detailed data on patient selection, decision making, and the postoperative course of this surgical procedure became available through individual case reports. In this historical context, a report written in 1641 by the Dutch physician Dr. Nicolaes Tulp is remarkable. This report, one of the first individual commentaries on the surgical treatment of an acute epidural hematoma, has not yet gained international recognition.

Operative treatment of spontaneous spinal epidural hematomas: a study of the factors determining postoperative outcome.

OBJECTIVE: We clarify the factors affecting postoperative outcomes in patients who have suffered spontaneous spinal epidural hematomas. METHODS: We review 330 cases of spontaneous spinal epidural hematomas from the international literature and three unpublished cases of our own. Attention was focused on sex, age, medical history, mortality, size and position of the hematoma, vertebral level of the hematoma, preoperative neurological condition, operative interval, and postoperative result. RESULTS: Sex, age, and size and position of the hematoma did not correlate with postoperative outcome. Mortality correlated highly with cervical or cervicothoracic hematomas, especially in patients with cardiovascular disease and those undergoing anticoagulant therapy. Incomplete preoperative sensorimotor deficit correlated highly with favorable outcomes (P < 0.0005), and recovery was significantly better when decompression was performed in < or = 36 hours in patients with complete sensorimotor loss (P < 0.05) and in < or = 48 hours in patients with incomplete sensorimotor deficit (P < 0.005). CONCLUSION: The critical factors for recovery after spontaneous spinal epidural hematoma are the level of preoperative neurological deficit and the operative interval. The vertebral level of the hematoma did not correlate with postoperative results, which suggests that local compression, rather than vascular obstruction, is the main factor in producing neurological deficit.

Chemonucleolysis versus discectomy: a randomized multicenter trial.

A randomized clinical trial was carried out to compare the results of open discectomy with those of chemonucleolysis in 151 patients suffering from a disc herniation at L4-5 or L5-S1. All patients fulfilled strict entry criteria; 78 patients underwent open discectomy and 73 were subjected to chemonucleolysis. An increase in radicular pain immediately after treatment was encountered in 16 patients (22%) in the chemonucleolysis group, as compared to none in the discectomy group. The efficacy of discectomy appeared to be definitely superior to that of chemonucleolysis. Within a follow-up period of 1 year, 18 patients (25%) required open discectomy following failed chemonucleolysis; two patients (3%) in the discectomy group needed a second operation. Open discectomy following previous chemonucleolysis was successful in only 44% of cases. Comparison of the final results of the two modes of treatment 12 months after the last intervention (including second treatment) did not reveal any significant differences. The duration of the preoperative symptoms, the level of disc herniation, and the leakage of contrast medium out of the disc appeared to be of no relevance to the final outcome. The complication rates in both treatment groups were low.

Pathogenesis and histopathology of saccular aneurysms: review of the literature.

In this paper, the major theories on the formation and growth of saccular aneurysms are reviewed on the basis of previous clinical, pathological and experimental studies. Which is the critical layer is still the focus of debate. Current ideas can be summarized as follows: most researchers think that disruption of the internal elastic lamina is an essential requirement for the creation of saccular aneurysms because it is this layer that provides most of the strength to the arterial wall, especially in cerebral arteries. Degeneration of this layer is a constant feature of all saccular aneurysms. A coexisting medial defect and haemodynamic stress at an apex may aggravate degeneration at that point. Hypertension does not seem to be the major factor in some aneurysm patients, but it may facilitate the formation and growth of saccular aneurysms. An atheroma is often associated with saccular aneurysms, but its effect on this pathological process is still unknown. Other factors are discussed concisely. Previous experimental methods and their results pertaining to the formation and growth of this type of aneurysm are also reviewed. A reproducible animal model is still required to allow various theories to be tested.

A method for temporary and repeated increase of blood pressure in the rat, using intraperitoneal adrenaline injections.

In experimental studies, permanent hypertension has been considered to be an important factor in aneurysm formation and growth. However, in clinical studies it has been found that saccular aneurysms often develop and rupture in some patients without persistent hypertension. Environmental events that temporarily and repeatedly increase blood pressure do not take an equivalent length of time in vivo but have been noted as factors in the growth or rupture of saccular aneurysms. In order to test the effect of intermittent blood pressure elevations on saccular aneurysm formation and growth, a reliable method for temporarily and repeatedly increasing blood pressure should be developed first and in this paper, such a model is described. It is based on the intraperitoneal injections of adrenaline in rats, a route which does not seem to have been used so far.

An acute experimental model of saccular aneurysms in the rat.

A new and reproducible saccular aneurysm model has been developed at the bifurcation of the common carotid artery in rats. The details of the experimental methods and results are described. It is strongly suggested that the internal elastic lamina is a critical layer in saccular aneurysm formation, because an experimental saccular aneurysm can be produced immediately by transluminally damaging the inside of the arterial wall at the bifurcation of the common carotid artery. This saccular aneurysm model has several advantages: (i) it can be induced quickly and the success rate approaches 100% in rats; (ii) this technique can produce satisfactory experimental saccular aneurysms for other aneurysm studies, and in the future it will also be possible to use this technique to produce experimental saccular aneurysms in cerebral arteries of large animals.

Observations on experimental saccular aneurysms in the rat after 2 and 3 months.

After 2 and 3 months we re-exposed 20 experimental saccular aneurysms. Under the operating microscope, we measured their sizes and compared them with the sizes immediately after induction. All aneurysms had grown significantly and none was thrombosed. Pathological examinations showed that the sac of the aneurysm was similar to that of the human saccular aneurysms. Based on the operating microscopy and pathological findings we postulate that abnormal histological structure and haemodynamic stress are the major causes of aneurysm enlargement. We also noted that there were some regenerative processes in these experimental aneurysm walls. The results prove that this model is reliable, because these aneurysms have the main characteristics of human saccular aneurysms, not only grossly but also microscopically.

Pathological changes in experimental saccular aneurysms in the carotid artery of the rat.

Although the reason for development of saccular aneurysms in humans has still not been elucidated, the process might be observed and explained using a reproducible aneurysm model in vivo. In this paper, a sequential pathological study of the experimental saccular aneurysms was made. No additional influential factors were applied. At all stages of the development between the induction and 6 months, the histology of the aneurysm wall was similar to that of human aneurysms. The imbalance of the degeneration and regeneration processes during the development of these experimental aneurysms is discussed according to the pathological findings in different periods. Haemodynamic stress and different regenerative speeds in different arterial tissues must be responsible for the saccular aneurysm formation and growth.

Effect of contralateral carotid ligation on experimental carotid artery aneurysm in the rat.

Haemodynamic factors in the formation and development of saccular aneurysms have been widely studied. Saccular aneurysms could appear and grow at the side of the increased blood flow. The effects of contralateral carotid ligation on the formation and growth of our experimental saccular aneurysms were studied. Measurement and pathological examination showed that the haemodynamic changes could facilitate the development of saccular aneurysms, but by itself could not bring about their formation.

Effect of intermittent blood pressure elevation on the growth of experimental saccular aneurysms in the rat.

In this study we applied the technique described in the previous paper (see pp. 103-106 of previous issue (1991); 13(2)) to rats with experimental saccular aneurysms. We found that the mean sizes and some growth ratios of experimental aneurysms were significantly larger in the intermittent blood pressure elevation groups than in the control groups. The increase of growth ratios was proportional to the number of transient blood pressure elevations. The morphological structure of these saccular aneurysms showed that the regenerative processes in the aneurysm wall had obviously been interfered with in animals with intermittent blood pressure elevation. The effective mechanism of this influential factor is discussed.

Fluorescence localization in tumour and normal brain after intratumoral injection of haematoporphyrin derivative into rat brain tumour.

In the intracerebral 9L rat gliosarcoma, the spatial distribution of the photosensitizer haematoporphyrin derivative (HpD) was studied after intratumoral injection. The fluorescence volume was measured in histological sections from 10 min up to 5 days after injection. Complete sensitization of the tumours could not be achieved by slow stereotactical injection of 4 mm3 HpD (mean HpD fluorescence volume, 13 +/- 11 mm3). Larger parts of the tumour could be loaded with HpD (39 +/- 23 mm3, p = 0.0001) by increasing the injection velocity and the volume to 50 mm3. Again, complete sensitization of the tumours was not achieved during a time scale of 5 days after intratumoral injection. Although the fluorescence volume did not change significantly with time, it was influenced by the injection site within the tumour. Injection of HpD within 1 mm from the tumour border resulted in significantly smaller fluorescence volumes in the tumour than injection into the tumour centre. Large injection volumes caused an increased leakage of HpD to normal brain, leading to the loss of selectivity of photosensitizer content and the occurrence of dark toxicity of normal brain while the tumours still appeared vital.

Kinking of the carotid artery: indications for surgery and surgical procedure.

In seven patients surgical correction of kinking with stenosis of the extracranial part of the carotid artery was performed. The indications for surgical treatment of carotid kinking are discussed in detail. The following criteria for surgical correction are applied: 1. symptoms of cerebral ischemia must be present; 2. position or motion of head and neck can provoke symptoms; 3. definite stenosis of the corresponding carotid artery at the level of kinking; 4. no other causes of cerebral ischemia; 5. no irreversible brain infarction. A simple and effective surgical procedure as a routine method for correction of carotid kinking is described. Only in special circumstances a more extensive open arterial reconstruction might be necessary.

Multiple cerebral de novo aneurysms.

The new development of two remarkable cerebral mirror aneurysms is described in two female patients, who had been surgically treated for a mid-line aneurysm several years previously. The phenomenon of mirror aneurysms makes it likely that an inborn weakness of the vessel wall is one of the underlying causes of cerebral aneurysms. Acquired alterations of the vessel wall and hemodynamic forces, on the other hand, also play an important role in the genesis of aneurysms.

Ventriculo-peritoneal shunt procedure complicated by liver capsule perforation. A case report.

A 29-year-old woman in childbed, presented with obstruction hydrocephalus due to a cerebellar spongioblastoma, was treated by ventriculo-peritoneal shunting. The peritoneal spring catheter used in this procedure caused a perforation of the liver capsule. The type and length of a catheter appropriate to such a case are discussed.

Paraganglioma of cauda equina.

After a brief introduction to the problem of the nature and localisation of sympathetic and parasympathetic paragangliomas a new case of paraganglioma of cauda equina is reported.

Clinical assessment of a novel antiadhesion barrier gel: prospective, randomized, multicenter, clinical trial of ADCON-L to inhibit postoperative peridural fibrosis and related symptoms after lumbar discectomy.

A prospective, multicenter, randomized, double-blind, controlled study of ADCON-L Anti-Adhesion Barrier Gel (a medical device by Gliatech Inc, Cleveland, OH) was conducted in 298 patients undergoing first-time lumbar discectomy to evaluate the safety and effectiveness of ADCON-L in preventing postoperative peridural fibrosis and in improving patient clinical outcome. After lumbar discectomy, patients were randomized to receive either ADCON-L gel or nothing (control group) at the conclusion of the surgical procedure. Six months after surgery, peridural scar was evaluated by magnetic resonance imaging, and postoperative pain and straight-leg-raise angle were assessed. No statistically significant differences between the ADCON-L and control groups were observed in terms of adverse events or wound healing characteristics. ADCON-L gel was shown to be safe and to significantly inhibit peridural scar compared with the control group (P = 0.002). That peridural scarring was reduced with ADCON-L gel was further supported by direct visualization of scar tissue at reoperation in both groups. ADCON-L-treated patients had better clinical outcomes than did control patients. The incidence of activity-related pain was significantly reduced (P = 0.013), straight-leg-raise examination scores were significantly improved (P = 0.024 on the operative side and P = 0.015 on the nonoperative side), and ADCON-L reduced low back pain when it was most severe (P = 0.047) and at the end of the day (P = 0.044).

[Revised guidelines for the treatment of patients with severe traumatic brain injury]. / Herziene richtlijnen voor de behandeling van patiënten met ernstig traumatisch hersenletsel.

The early assessment and acute treatment of patients with severe traumatic brain injury require a well structured and organized policy. This policy should include rapid transport to, and effective first aid in trauma centres especially equipped for this purpose, adequate communication of information between the (para-)medical workers successively involved and a multidisciplinary handling of diagnostics and treatment of the various traumatic and posttraumatic conditions. This requires the imposition of unequivocal priorities known to all concerned. In this paper, which was written in cooperation with the different medical disciplines concerned, the main features of the acute treatment of severe head injury, about which a wide agreement was reached, are worked out in 18 theses. The guidelines regard the admission and first aid, the diagnostic procedures and the conservative and surgical treatment of patients with severe head injury. These guidelines can be developed in the different hospitals into detailed blueprints for the treatment, in accordance with the local situation.