[Neurosurgical therapy of epilepsy]. / Zur neurochirurgischen Therapie der Epilepsien.

We are witnessing a renaissance of the surgical treatment of epilepsy, with renewed interest in the classic procedures and development of new ones such as selective amygdalohippocampectomy. Surgery is being increasingly used in the treatment of medically intractable seizures. Exact presurgical evaluation, with definition of the focus, is of the utmost importance and good results are largely dependent on case selection for surgical therapy. The various therapeutic options such as temporal lobectomy, selective amygdalohippocampectomy, extratemporal cortical resections, hemispherectomy and corpus callosotomy are described and the risks and benefits of surgery discussed. Selective amygdalohippocampectomy, anterior temporal lobectomy and hemispherectomy yield very rewarding results as regards seizure control, while corpus callosotomies frequently reduce the number and severity of generalized seizures.

[Intraventricular morphine administration as a treatment possibility for patients with intractable pain]. / Intraventrikuläre Morphingaben als Behandlungsmöglichkeit bei Patienten mit nicht beherrschbaren Schmerzen.

The treatment of intractable pain, especially in cancer patients, often sets problems to patient and therapist. While epidural and intrathecal spinal administration of opiates is a routine treatment in pain with a sub-diaphragmatic topography it is almost ineffective in cervicocephalic or thoracic cancer. An alternative here is the administration of morphine into the lateral or third ventricle by a catheter-reservoir system. We report on our experience in the treatment of twenty patients, mostly suffering from cancer (18 cases), from 1990 to 1993. It is shown to be an effective, non-destructive method with minimal side effects in the treatment of nociceptive pain. Analgesia takes effect within a few minutes and the necessary doses are low. Our results agree with those of other authors describing good to excellent results in 95% of patients with somatogenic pain. However, no or only minimal effect is achieved in the treatment of neurogenic pain by intracerebroventricular morphine therapy.

Three-dimensional computer assisted magnetic resonance imaging for neurosurgical planning in parasagittal and parafalcine central region tumors.

Usually, conventional magnetic resonance spin echo images (MRI) are sufficient to establish the diagnosis of intracranial pathology. Planning and executing a neurosurgical procedure requires the ability of the neurosurgeon to transform these two-dimensional MRI into a three-dimensional (3-D) virtual image of the pathology and the surrounding neuronal anatomy. Such mentally performed transformations after sequential observation of the individual two-dimensional slices (i.e., MRI and angiography) may be virtual tasks that are very difficult or sometimes impossible to achieve. Using 3-D MRI data sets and a semiautomatic computer assisted segmentation technique, we tried to simulate intraoperative situs-based 3-D MRI reconstructions of parasagittal and parafalcine central region tumors. The MRI reconstructions were integrated into the neurosurgical planning procedure as an additional tool. They proved to be an important adjunct in determining the distinct anatomy of the intracranial pathology in its relation to the surrounding and overlying brain and vascular (especially venous) anatomy. With 10 patients with central region parasagittal and parafalcine tumors, we found that the 3-D MRI reconstructions revealed additional information compared to conventional cross-sectional images and had an influence on neurosurgical planning and strategy, improving neurosurgical performance and patient outcome.

[Body image of anorexic girls, their mothers and sisters: a controlled study]. / Das Körpererleben magersüchtiger Mädchen, ihrer Mütter und Schwestern: Eine kontrollierte Studie.

Body image disturbance is a main diagnostic criterion for anorexia nervosa. However, its transmission in families has never been studied empirically. Our study compared the body experience of a consecutive series of 29 adolescent anorexics at initial assessment (DSM-III-R, mean age 14.4 years), their mothers (n = 29) and 9 sisters with a control group of 29 healthy girls (matched in age and education), their mothers (n = 29) and 10 sisters, using the Body Experience Questionnaire (Strauss u. Appelt 1983). Within-group comparison revealed no significant differences in the control group. Although anorexics showed a more negative body experience than their mothers and sisters, the between-group comparisons revealed no significant differences to healthy controls, neither in cases nor in their sisters. Surprisingly, mothers of anorexics reported a significantly more positive body experience than control mothers. Whereas in patients and their mothers a correlation of insecurity was found, the control mother-daughter-pairs revealed a correlation of attractiveness. In the transmission of body experience amongst female family members negative aspects seem to play a major role between mothers and their anorexic daughters, whereas positive aspects correlate significantly in healthy mothers and daughters; mothers of anorexics may communicate specific negative aspects of body experience to anorexic daughters or anorexics might be more susceptible to such messages. If further studies confirm our results, this should have consequences for treatment.

Hyperventilation reverses the nitrous oxide-induced increase in cerebral blood flow velocity in human volunteers.

Because hypocapnia is routine during general anaesthesia for intracranial procedures, we have compared, in 13 healthy volunteers, the effect of normocapnia (PE'CO2 5.3 kPa) and hypocapnia (PE'CO2 3.3 kPa) on mean blood flow velocity in the middle cerebral artery (Vmca) during normoventilation and hyperventilation with air and with 50% nitrous oxide in oxygen. After replacement of air with 50% nitrous oxide in oxygen, there was an increase in mean Vmca during normoventilation (air: mean 68.23 (SD 16.98) cm s-1 vs nitrous oxide in oxygen: 90.69 (20.41) cm s-1; P < 0.01), whereas during hyperventilation mean Vmca values were similar regardless of the inhaled gas mixture (air: 43.46 (9.97) cm s-1 vs nitrous oxide in oxygen: 41.69 (8.08) cm s-1. Our data suggest that the nitrous oxide-induced increase in mean Vmca can be blocked by hyperventilation.

Therapy of glioblastoma multiforme: a cumulative experience of 10 years.

PURPOSE: Comparison of the effect of different therapeutic modalities on survival time of patients with glioblastoma multiforme operated on during the last decade (1980-1990). PATIENTS AND METHODS: The records of 157 consecutive patients with the histological diagnosis of glioblastoma multiforme were analysed for survival with respect to age of patients, extent of surgery, influence of re-operation and adjuvant postoperative treatment. The latter included fractionated radiotherapy, chemotherapy (BCNU. CCNU with Vincristine) and photodynamic therapy (PDT). RESULTS: Analysis of variance showed a significant effect for survival after macroscopically radical surgery (p = 0.005), postoperative radiotherapy (p < 0.001), chemotherapy (p < 0.01). Low age (p < 0.05) and a postoperative Karnofsky performance score (KPS) > or = 60 (p < 0.001) had a positive influence: the site of tumour and pre-operative presence of seizures had no significant influence (p > 0.1) on survival time. CONCLUSION: We conclude that the current adequate management of glioblastoma multiforme should include surgical resection followed by adjuvant treatment such as radiotherapy and chemotherapy.

Virtual neuroendoscopy, a comparative magnetic resonance and anatomical study.

We evaluated the usefulness and reliability of intraventricular virtual neuroendoscopy based on a comparative anatomical study. Virtual intraventricular endoscopic images were calculated from 3D magnetic resonance images in five anatomic specimens. Contiguous 1.2 mm slices of the specimen heads were acquired at a 1.5 T MR scanner using a 3D-gradient echo sequence. The images were then transferred to an independent 3D-workstation (Sun Spark 20). After scanning the specimen heads, real endoscopy within the cerebral ventricles of these brains was performed with a standard rod lens system. Comparison between real and virtual endoscopic views of the intraventricular topography was based on the same anatomical reference and landmarks. Acquisition of MR data and virtual image post-processing have been possible in all specimens. The virtual endoscopic images of the ventricles were comparable to the intraventricular views obtained by a standard rod lens system. Virtual intraventricular neuroendoscopy can be employed for planning and simulating neuroendoscopic procedures. It enables the neurosurgeon to simulate the endoscopic procedure within the cerebral ventricles on the basis of the patient's individual anatomy prior to surgery.

Deep brain stimulation of the subthalamic nucleus for control of extrapyramidal features in advanced idiopathic parkinson's disease: one year follow-up.

UNLABELLED: Deep brain stimulation (DBS) of the subthalamic nucleus (STN) with a quadripolar electrode was carried out in 9 patients with advanced idiopathic Parkinson's disease (PD) affected with severe diurnal motor fluctuations. The effect of bilateral STN stimulation was evaluated by clinical methods in all patients after 3 and 12 months. Assessment was based on the Unified Parkinson's Disease Rating Scale (UPDRS), timed motor tests, the Schwab and England Activities of Daily Living and a diary chart to document motor fluctuations. Alterations in parkinsonian signs, motor performance and functional outcome were recorded postoperatively (1) under temporary complete withdrawal of both STN stimulation and medication; (2) in the presence of STN stimulation only; and (3) in the presence of both STN stimulation and medication. The results were compared with the preoperative data assessed in defined on-phase and defined off-phase. STN stimulation on (compared to STN stimulation off) results in a significant improvement in UPDRS motor scores: after 3 months from 50.5 +/- 14.3 to 27.8 +/- 5.8, and after 12 months from 49.4 +/- 14.1 to 27.1 +/- 7.1 (p < 0.01). There was a significant decrease in the average duration of off-periods from 8.82 +/- 2.47 hours to 1.00 +/- 1.06 hours (p < 0.001), a marked increase in on-periods without dyskinesia from 4.62 +/- 2.72 to 14.62 +/- 1.51 hours (p < 0.01), and a sharp drop in on-periods with dyskinesia from 2.87 (+/- 4.18) to 0.25 (+/- 0.97) hours (p < 0.05), which remained stable up to 12 months (off-periods: 1.25 +/- 1.58 hours, p < 0.001; on-periods without: 13.87 +/- 1.95 hours, p < 0.001; and on-periods wth dyskinesia: 0.37 +/- 1.06 hours, p < 0.05). However, our first PD patient with an implanted DBS electrode within the STN died from cardiac infarction two days after surgery. This sudden death was not linked either to surgery nor to stimulation - and happened by chance. Our findings confirm that STN stimulation is a suitable functional neurosurgical procedure for the modulation and control of PD signs associated with severe motor fluctuations, in that they demonstrate a beneficial effect which was fully sustained over a one year follow-up period. KEYWORDS: Subthalamic nucleus, deep brain stimulation, Parkinson's disease.