Follow-up after cervical laminectomy, with special reference to instability and deformity.

Misalignment and instability after cervical laminectomy, performed to treat spondylotic myelopathy, has been described as possible adverse effects. Forty-six consecutively patients on whom laminectomy had been performed in a 4-year period were identified; 7.7 +/- 0.6 years after operation, 11 patients had died and 27 patients were available for follow-up. Postoperative static subluxation was observed in 26% of the patients with an average slip of 3.7 +/- 3.1 mm; 7% had abnormal intervertebral movement displaying 1-2 mm movement from full flexion to full extension. Seventy-four per cent of the patients showed abnormal spinal curvature as judged from radiographs. However, no correlation with outcome was observed. Seventy-four per cent of the patients thought of the result of the operation as either good or fair; objectively, the best long-term effect of the operation was upon arm function. Although some patients develop postural anomaly, laminectomy remains, in terms of instability, a justifiable procedure in the elderly patient with spondylosis.

Corpus callosotomy: seizure and psychosocial outcome. A 39-month follow-up of 20 patients.

The aim of the present study was to investigate the effect of corpus callosotomy on seizures, with emphasis on the psychosocial outcome. Data were retrospectively obtained from 20 patients (mean age 20.8 years, range 6-46). Sixteen of the operated patients took part in the 39-month (range 19-62) follow-up. Outcome measures were post-operative seizures, changes in the antiepileptic drug treatment, surgical complications including disconnection syndrome, degree of dependency according to the Barthel index, quality of life, burden on caretakers and satisfaction with the treatment. Half of the patients had a favorable seizure outcome, and of these 50% noticed an improved quality of life and were satisfied with the treatment. Four patients suffered from symptoms of cerebral disconnection syndrome which interfered with the activities of daily life. One patient died of complications 3 months after the operation. There were no significant changes in antiepileptic drug treatment, the patients' social lives or the burden of the patients on the caretakers. The conclusion is that prospective studies are needed to clarify the criteria for optimal patient selection to increase the likelihood of a positive psychosocial outcome.

[Psychiatric morbidity in connection with surgical treatment of epilepsy. A short-term follow-up of patients with amygdalohippocampectomy]. / Psykiatrisk morbiditet i forbindelse med epilepsikirurgi. Korttidsopfølgning af amygdalohippokampektomerede patienter.

The aim of the study was to examine the occurrence of psychiatric disorders in epilepsy patients who had received surgical treatment, especially amygdalohippocampectomy (AHE), for the relief of medically intractable seizures. Forty-seven subjects, treated during the period 1987-1991 in the Danish epilepsy surgery programme (EPIKIR), entered a retrospective interview study. Of these, 37 had undergone AHE. Preoperative psychiatric morbidity was assessed through interview and available case notes, including a routine psychiatric interview. Postoperative psychiatric morbidity was assessed by the use of the Present State Examination. A total of six subjects (five AHE subjects) developed depressive disorders of various duration and severity after operation. In three subjects this occurred "de novo". No paranoid-hallucinatory psychoses developed within the follow-up period (a minimum of one year), and the presence of psychiatric disorders could not be associated with either lateralization of cerebral dominance of histopathological findings. Thus, depression appears to be the most frequent psychiatric problem following epilepsy surgery. Although the present study mainly deals with AHE, this finding is in accordance with the results of recent findings concerning anterior temporal lobe resection.

A case of cerebral paragonimiasis in Denmark. Case report.

A case of cerebral paragonimiasis with severe neurological symptoms is presented. The patient, a 45-year-old woman, recovered completely after resection of a large cyst at the C3 level. The pathogenesis is discussed.

Psychiatric morbidity after surgery for epilepsy: short-term follow up of patients undergoing amygdalohippocampectomy.

The aim was to assess the occurrence and type of psychiatric disorders of patients with medically intractable epilepsy in relation to surgical treatment, with special reference to amygdalohippocampectomy (AHE). The design was a retrospective psychiatric interview study, including Present State Examination (PSE) and diagnostic classification according to the International Classification of Diseases--8th revision (ICD-8) and ICD-10. Forty seven (94% of total) patients operated on between 1987 and mid-1991 in the Danish epilepsy surgery programme were studied. The main group of interest included 37 patients treated by AHE. The presence of psychiatric disorders before and after operation was assessed by PSE (including the Catego classification) and by ordinary clinical procedures, making use of all available information (hospital case notes and presurgical psychiatric assessments independent of the study). Four patients in the AHE group developed depressive disorders of various durations and severity after operation (in three (8%) patients these occurred de novo). One other patient with AHE with a presumed personality disorder who underwent AHE developed a severe depression, as did one patient after a lesionectomy. No patients developed new paranoid hallucinatory psychoses. No association was found between presence of psychiatric disorders and neither right sided cerebral dominance nor histopathological findings. In conclusion, the postoperative psychiatric morbidity in this sample of patients treated with AHE is of the same magnitude as described in recent series of patients undergoing temporal lobe resection for medically intractable epilepsy. Likewise, affective disorders (depressive conditions) constitute the most prominent psychiatric problem after surgery for epilepsy.

Immunohistochemical and chromatographic identification of peptides derived from proneuropeptide Y in the human frontal cortex.

Proneuropeptide Y (proNPY) is posttranslationally processed to NPY(1-36)amide and the C-terminal flanking peptide of NPY (CPON). Antisera directed against the N-terminal part of NPY, CPON, or CysNPY(32-36)amide were used to identify peptide fragments processed from proNPY in biopsies of human frontal cortical specimens obtained from patients who underwent surgical treatment of profound cerebral tumors. Gel filtration and radioimmunoassays of human cortical extracts revealed that the NPY immunoreactivity was found only as NPY(1-36)amide, indicating that all NPY is present in an amidated form. In contrast, no intact proNPY was identified. NPY/CPON-immunoreactive neurons were observed to be nonspiny with long axonal processes mostly orientated longitudinally in the direction of the superficial layers. Bundles of immunoreactive fibers in the underlying white matter were orientated toward superficial layers of the neocortex, indicating a subcortical origin of some NPY/CPON nerve fibers. Axonal terminals were distributed throughout the neocortex, with highest numbers observed in layer I. Some fibers penetrated from the superficial layer I into the overlying pial surface. Many fibers were also observed in proximity to intracortical blood vessels, and some of these fibers originated from the cortical neurons, indicating that NPY could play a role as an intracortical autoregulator of the tonus of cerebral arterioles. Together these results indicate that NPY(1-36)amide and CPON are present in intracortical neurons as two independent molecules and that NPY may be involved in synaptic processes and regulation of blood flow in the human brain.

[Surgical treatment of epilepsy resistant to drug therapy. A review]. / Kirurgisk behandling af medikamentelt intraktabel epilepsi. En oversigt.

The prevalence of epilepsy is 7-9 cases per 1,000 population, corresponding to 440,000 individuals in Denmark. Approximately 1/4 of these individuals have seizures refractory to anticonvulsant medications and most of them have an epileptic focus in the temporal lobe. Epilepsy refractory to anticonvulsant medication is an incapacitating disease with high costs for the person and the society. The main problems are polypharmacy with side effects, suspicion of neurodegenerative consequences and a higher mortality. The modern era of epilepsy surgery began more than 100 years ago and since then, the developments in neurophysiology and neuroimaging have made it possible to demonstrate the epileptic focus with relatively high precision. As a consequence of this, the volume of the resected tissue has diminished and the operative complications become less frequent. The somatic and neuropsychological effects of a cortical resection are discrete and compensated by a general improvement in performance. Surgical treatment of epilepsy should no longer be considered as a last resort, but as a realistic treatment in cases of medication failure.

Central nervous system reactions to cervical myelography.

In a double blind prospective study of side effects to cervical myelography 38 patients were evaluated with neurologic examination, electroencephalography (EEG), brainstem evoked response (BER), somatosensory evoked responses (SSER), and continuous reaction times prior to and at 6 h and 24 h after myelography with either metrizamide or iohexol. A difference in the incidence of side effects (for example headache, dizziness, nausea, and neck pain) to the two different contrast media indicated that the inconveniences related to myelography were not only due to the spinal puncture. A contrast medium effect on the central nervous system varying from one agent to another was present. A high frequency of EEG deteriorations among patients with adverse clinical reactions and on only discrete affection upon BER indicated the reaction to be located to the cerebral cortex. Weakened tendon reflexes and reduced strength in the upper extremities were probably caused by blockade in the motor roots as SSER were normal indicating no affection of the sensory pathways. This hypothesis is in agreement with the fact that the patients were in the prone position in the first phase of the investigation causing the highest concentration of contrast medium around the motor roots and the anterior part of the spinal cord. Difference in metabolic effect may explain differences in side effects of metrizamide and iohexol.

Anosmia following operation for cerebral aneurysms in the anterior circulation.

Damage to the olfactory nerve during frontotemporal approach to the basal cisternal region has not previously been investigated in a quantified manner. In this retrospective study of 25 patients operated on for ruptured intracranial aneurysms via the frontotemporal route, 22 patients suffered postoperatively from anosmia ipsilateral to the side of surgery. This complication most often goes unrecognized by the patient as well as the physician, and attention should be drawn to it because of its widespread occurrence. This investigation demonstrates a high incidence of anosmia (24 (88.9%) of 27 surgical sides) occurring ipsilateral to the frontotemporal approach in aneurysm surgery. Recovery after traumatic anosmia has been recorded up to 5 years after injury. Nevertheless, the authors believe that the damage is permanent when lasting 35 months or longer.

[Practical use of the brain death diagnosis]. / Hjernedødsdiagnosen i praktisk anvendelse.

A retrospective review of a material spontaneous intracerebral haemorrhages and head injuries from a period of five years revealed that 14% of the patients with these diagnoses eventually are diagnosed as brain dead. In half of the brain dead patients cerebral angiography was carried out and, in all of the cases, this revealed circulatory arrest in the brain. The investigation demonstrates that, on the average, 8.5 hours elapse from the establishing of the diagnosis of brain death until cardiac arrest occurs. In 75 out of 105 cases, relations were asked for permission to remove organs and the reply was affirmative in 52 cases (69.3%). Two patients had already consented to organ donation.

An immunohistochemical localization of neuropeptide Y (NPY) in its amidated form in human frontal cortex.

The distribution of neuropeptide Y (NPY)-immunoreactive neurons was studied in human frontal cerebral cortex from surgical biopsy specimens by immunohistochemical techniques. NPY-containing neurons were identified in all cortical sublayers except sublayer I. The stained neurons were of the multipolar, bitufted, round or triangular form with dendritic and axonal processes. The immunoreactive neurons were considered to be cortical interneurons, due to their nonpyramidal form, and since their processes could be followed intracortically particularly in direction to superficial cortical layers. The NPY precursor molecule is processed to NPY by a dibasic cleavage, and NPY is further enzymatically amidated before release and receptor activation can be achieved. Antisera raised against Cys-NPY(32-36)amide recognize amidated NPY not cross-reacting with nonamidated NPY. These antisera and immunohistochemistry revealed the presence of a population of NPYamide-immunoreactive cells morphologically indistinguishable from the NPY-immunoreactive cells in the human frontal cortex. By comparing the number of immunoreactive cells in adjacent sections, it appears that the number of NPY-immunoreactive cells was higher than those immunoreactive to NPYamide. Also, the density of NPY fibers was much higher compared with the number stained with NPYamide antiserum. The present immunohistochemical study indicates that NPY in its amidated form is contained in a subpopulation of human cortical NPY-immunoreactive neurons and may participate as an active neurotransmitter/modulator within the human cerebral cortex.

SPECT in the presurgical evaluation of patients with temporal lobe epilepsy--a preliminary report.

Twenty-eight patients with drug resistant temporal lobe epilepsy (DRTLE) were studied using single photon emission computed tomography (SPECT) using xenon-133 inhalation and Tc99m-d, 1-HMPAO with TOMOMATIC 64 as part of a presurgical evaluation programme. The visually evaluated flow-images were studied after blinding and the results subsequently compared to the EEG, MRI and CT scanning studies. In 24 patients a significant low flow region was seen in one temporal lobe. The SPECT result corresponded to the EEG findings in all but 6 patients. In 2 of these patients no side localization was indicated by EEG, while in four patients the EEG suggested that the opposite side was epileptogenic. Ictal SPECT and MRI/CT agreed with the resting SPECT study in three patients, while one patient has remained undiagnosed with respect to side-localization. In 14 patients discordance between SPECT and the CT scan was observed, but in 11 of these patients the SPECT study correlated with the other focal diagnostic tools. In 11 of the 21 patients studied by MRI, the results corresponded to SPECT; in 7 of the 10 which did not correspond, ictal studies of EEG and SPECT defined the side, in four of these 7 patients. Using the neuroimaging tools in concert 16 patients have been selected for surgery. All patients have benefited from surgery. These preliminary results correspond favourably with earlier studies comparing SPECT and PET with CT, MR and EEG.

Glucocorticoid receptors in glioblastoma multiforme: a new approach to antineoplastic glucocorticoid therapy.

Glucocorticoid receptors were measured in tissue samples from 12 patients with glioblastoma multiforme. The receptor was found in all patients. The concentration of glucocorticoid receptor was found to be high in the periphery of the tumour, low in the surrounding brain tissue and low in the central part of the tumour in 6 of the patients. The possible role of the glucocorticoid receptor distribution in relation to growth regulation is discussed. A decreasing receptor concentration found at reoperation in two patients indicates a possible antineoplastic effect of high dose methylprednisolone pulse therapy on glucocorticoid receptor positive glioblastomas.

Cerebral blood flow and metabolism during isoflurane-induced hypotension in patients subjected to surgery for cerebral aneurysms.

Cerebral blood flow and cerebral metabolic rate for oxygen were measured during isoflurane-induced hypotension in 10 patients subjected to craniotomy for clipping of a cerebral aneurysm. Flow and metabolism were measured 5-13 days after the subarachnoid haemorrhage by a modification of the classical Kety-Schmidt technique using xenon-133 i.v. Anaesthesia was maintained with an inspired isoflurane concentration of 0.75% (plus 67% nitrous oxide in oxygen), during which CBF and CMRO2 were 34.3 +/- 2.1 ml/100 g min-1 and 2.32 +/- 0.16 ml/100 g min-1 at PaCO2 4.1 +/- 0.1 kPa (mean +/- SEM). Controlled hypotension to an average MAP of 50-55 mm Hg was induced by increasing the dose of isoflurane, and maintained at an inspired concentration of 2.2 +/- 0.2%. This resulted in a significant decrease in CMRO2 (to 1.73 +/- 0.16 ml/100 g min-1), while CBF was unchanged. After the clipping of the aneurysm the isoflurane concentration was reduced to 0.75%. There was a significant increase in CBF, although CMRO2 was unchanged, compared with pre-hypotensive values. These changes might offer protection to brain tissue during periods of induced hypotension.

Observer variability in assessment of angiographic vasospasm after aneurysmal subarachnoid haemorrhage.

In clinical practice and in many reported studies about incidences and time courses of vasospasm the angiographic spasms are judged by eye without clear definition of vessel narrowings. To evaluate the reliability of this diagnostic method two experienced neuroradiologists and two experienced neurosurgeons independently in two sessions, examined 30 carotid angiograms performed after an aneurysmal subarachnoid haemorrhage. The intra- and inter-observer agreements for the absent/present and localization diagnosis of vasospasm were calculated by means of Kappa statistics. Kappa values for both intra- and inter-observer agreement showed great variability and in general most of the agreements were not much better than chance expected agreement. The diagnostic method of judging angiographic vasospasm by eye without clear-cut definitions of vessels narrowings is unreliable and should not be used in the future, neither in clinical practice nor in research.

Antibiotic prophylaxis in cerebrospinal fluid shunting: a prospective randomized trial in 152 hydrocephalic patients.

The authors report a prospective, randomized 18-month study on the effect of prophylactic antibiotic treatment in 152 hydrocephalic patients in whom clean shunt operations or revisions were done. The treated group received methicillin (totally 200 mg/kg) divided into six i.v. doses during 24 hours starting at the induction of anesthesia. Patients allergic to penicillin received erythromycin instead. Seventy-nine patients received antibiotics, and 73 (the control group) received none. All patients were followed at least 6 months after operation or to their death. Eleven patients developed signs of infection, giving an overall infection rate of 7.2%; however, the infection occurred less than 1 month after the operation in only half of these. Six of the patients had septicemia, 4 had peritonitis, and 1 had meningitis. In the treated group, the infection rate was 8.9%; in the control group, the rate was 5.5%. There was no statistically significant difference. The prophylactic antibiotic regimen in this investigation did not reduce the infection rate connected with cerebrospinal fluid shunting procedures.

Gastrin and cholecystokinin in human cerebrospinal fluid. Immunochemical determination of concentrations and molecular heterogeneity.

To determine whether gastrin and cholecystokinin (CCK), recently found in the central nervous sytem, were present in cerebrospinal fluid (CSF), we studied human specimens by sensitive and specific radioimmunoassays for the two related polypeptide hormones. The concentration of gastrin in cerebrospinal fluid from 10 neurologically normal persons ranged from 1.5 to 8.0 pM (mean 3.4 pM), whereas the concentration of CCK ranged from 4 to 55 pM (mean 14 pM). The molecular heterogeneity of gastrin and CCK in CSF was determined by gel chromatography of concentrated fluid monitored by 3 gastrin radioimmunoassays specific for different sequences of gastrin17 and 3 CCK radioimmunoassays specific for different sequences of CCK33. Chromatography revealed that gastrin was present in molecular forms corresponding to gastrin34 ('big gastrin') and gastrin17. CCK was present in molecular forms corresponding to the COOH-terminal octapeptide amide of CCK33 and a fragment corresponding to sequence 25-29 of CCK33. Also, a peptide corresponding to COOH-terminal tetrapeptide amide common to both gastrin and CCK was found. The results indicate that true gastrin as well as CCK are present in CSF, and that both hormones display a molecular heterogeneity similar to that found in extracts of brain tissue.