Expression of cell proliferation markers in pituitary adenomas--correlation and clinical relevance of MIB-1 and anti-topoisomerase-IIalpha.

Pituitary adenomas represent an inhomogeneous tumor entity in terms of growth rate, invasiveness and recurrence. To improve understanding of their different biological behaviour, tumor cell proliferation markers are applied. The aim of this study was to assess proliferation rates overall and in clinico-pathological subgroups using MIB-1 and the recently introduced cell proliferation marker anti-topoisomerase-IIalpha (Topo-IIalpha). Further, we correlated the two markers, and defined the clinical value of Topo-IIalpha in pituitary adenomas as compared to MIB-1. We analyzed tumor cell proliferation rates using MIB-1 and Topo-IIalpha antibodies on samples of 260 primary pituitary adenomas. We excluded recurrent cases and cases with drug pretreatment. Median patient age at the time of surgery was 47 years (range 14-86 years), the male:female ratio was 1:1. The total cohort comprised 110 non-functioning and 150 functioning cases. Subtyping was performed according to hormonal expression as defined by WHO. Tumor size and invasiveness were noted from surgical and/or radio logical reports in 95% of cases. Overall MIB-1 index was median 1.8% (range 0.2-23.6%), Topo-IIalpha index was median 1.0% (range 0-14.4%) with a strong correlation between the two markers ( R=0.837, P<0.001). As compared to MIB-1, mean Topo-IIalpha values were significantly lower by a factor 1.8. Only MIB-1 was significantly higher in invasive as compared to non-invasive adenomas, in tumors < or =3 cm in diameter, and in the age-group 21-40. Female gender had significantly higher MIB-1 and Topo-IIalpha indices than male. Silent ACTH-cell and PRL-producing adenomas had the highest, null-cell adenomas and gonadotropinomas the lowest proliferation values, respectively. Our data show a strong correlation between MIB-1 and Topo-IIalpha indices in pituitary adenomas. Only MIB-1 but not Topo-IIalpha demonstrated significantly higher values in invasive adenomas. Therefore, MIB-1 seems more useful than Topo-IIalpha for decisions regarding postoperative patient management.

Use of ADCON-L to prevent peridural fibrosis following re-operation for recurrent lumbar radiculopathy: clinical results.

OBJECTIVE: To present the results of a small retrospective study in patients after they have undergone lumbar scar resection and ADCON-L application to prevent recurrent formation of peridural fibrosis. PATIENTS AND METHODS: Between May 1996 and December 1999 nineteen patients underwent surgery for peridural fibrosis. Sixteen patients were eligible for statistical analysis. The mean age was 46.2 years (range 29 to 69 years) and the mean follow-up period was 9.7 months with a range of 3 to 38 months. In 10 patients scar formation was the main factor for nerve root compression. Three out of these patients showed concomitant recurrent disc herniation. Six patients presented with peridural fibrosis but concomitant recurrent disc herniation as the main factor for clinical deterioration. After scar resection and decompression of the nerve roots ADCON-L was applied intraoperatively. RESULTS: Excellent or good results (Prolo score 8 - 10) were achieved in 5 of 16 patients, fair results (Prolo score 6 - 7) in 5 and poor results (Prolo score 2 - 5) in 6 patients. CONCLUSION: ADCON-L may improve the chances of a satisfactory outcome in a small subgroup of patients following scar resection in the postoperative course of lumbar discectomy. Further investigations are necessary to identify clinical and radiographic factors predicting outcome.

Cubital tunnel syndrome. Treatment by decompression without transposition of ulnar nerve.

Cubital tunnel syndrome is the second most common entrapment neuropathy in the upper limb; however, surgical treatment of the ulnar nerve entrapment at the elbow remains controversial. None of the presently advocated procedures (simple decompression of the ulnar nerve, medial epicondylectomy, subcutaneous, submuscular or intramuscular anterior transposition of the ulnar nerve) has proven optimal regarding long-term results. This paper presents the experience of treating cubital tunnel syndrome with simple decompression in 40 patients. Three months after surgery 23/36 patients did not feel any pain in their operated hands. In 11/36 cases we observed an improvement of preoperative pain. Sensory disturbances disappeared completely in 24/40 cases. 11/40 patients reported an improvement of preoperative dysesthesia or hypesthesia. In 12/22 patients we observed complete recovery of preoperative pareses of adductor muscle of thumb or hypothenar muscles weakness. 7/22 cases demonstrated an improvement of these pareses. In total 28 patients (70 %) had an excellent outcome without residual symptoms. For 5 patients treatment results were classified as good with slight residual pain and sensory disturbance (12.5 %). In 4 cases (10 %) we only observed a fair outcome with persistent severe sensory and motor deficits but slow improvement over the last three months. Three patients did not demonstrate any improvement (7.5 %). The mean duration of postoperative disablement in our working patients (18/40) was 28 days. In summary, simple decompression of the ulnar nerve seems to be an adequate and successful minimally invasive technique for the treatment of cubital tunnel syndrome.

The influence of surgical experience on the rate of intraoperative aneurysm rupture and its impact on aneurysm treatment outcome.

BACKGROUND: The influence of surgical experience on the result of aneurysm surgery remains unclear. To determine the impact of surgical experience we considered the occurrence of intraoperative aneurysm rupture (IAR) during microneurosurgery for intracranial aneurysms as an objective factor that could be evaluated. METHODS: A retrospective study was performed on 379 consecutive patients with 490 cerebral aneurysms operated upon from 1989 to 1995. RESULTS: IAR occurred in 6.7% of aneurysms and 8.7% of patients. There was a direct inverse relationship between the annual caseload of the surgeon and the risk of IAR. New neurological deficits (NND) occurred in 21% of patients with IAR, which accounts for 1.8% of NND in all patients with aneurysms. CONCLUSION: Although there seems to be a direct relationship between surgical experience and the risk of IAR, the impact on the overall treatment outcome of cerebral aneurysms is rather limited.

The role of endoscopy in the treatment of acute traumatic anterior epidural hematoma of the cervical spine: case report.

OBJECTIVE AND IMPORTANCE: Epidural hematoma (EDH) of the spine represents an uncommon neurosurgical disorder that sometimes requires emergent surgical decompressive therapy. Traumatic EDH of the cervical spine is exceedingly rare. The hematoma is usually located dorsally in the epidural space. We present one case of acute EDH located ventrally in the cervical spine. Special emphasis is placed on the role of spinal endoscopy in surgical treatment. CLINICAL PRESENTATION: After a fall from a tree, a 69-year-old man with rapidly increasing tetraparesis was referred to our institution. Plain films of the cervical spine revealed nothing abnormal. The results of computed tomography were highly suspicious for EDH. A myelogram and a post-myelographic computed tomographic scan demonstrated the lesion and its extent craniocaudally. INTERVENTION: Emergency decompressive surgery and removal of the hematoma were performed via an anterior approach. Control for total removal of the EDH was achieved using a flexible neuroendoscope providing visualization of the anterior epidural space from the foramen magnum to the T1 level. Surgery was accomplished by vertebral body replacement and anterior plating. CONCLUSION: Spinal endoscopy seems to be a useful tool in the surgical treatment of spinal EDH, providing control of the adjacent levels and allowing the limitation of the extent of bony resection.

The preoperative assessment of stroke risk in lesions involving the internal carotid artery.

Patients with vascular or tumourous lesions involving the internal carotid artery are at risk of damage or occlusion of this vessel during surgical or endovascular procedures. To assess the stroke risk transcranial Doppler aided carotid compression tests were performed in 82 patients. Based on changes of blood flow velocity (BFV), pulsatility index, systolic/diastolic ratio and length of transient hyperaemic response three groups could be differentiated. Patients in group A (31%) showed only a slight reaction of BFV and were at minimal risk in case of carotid occlusion. Patients in group B (52%) underwent a distinct decrease of Doppler readings with partial improvement and were considered to have moderate to high stroke risk. In group C patients (17%) trial occlusion caused a dramatic reduction of BFV with no recovery (p < 0.01), which denotes a very high stroke risk. Transcranial Doppler aided carotid occlusion manoeuvres provide useful information on cerebrovascular collateral capacity and prognosis of stroke risk.

Aneurysm surgery of patients in poor grade condition. Indications and experience.

Out of a total of 196 patients admitted with aneurysmal subarachnoid haemorrhage (SAH) to the neurological department in Mainz over a 42 month period, 48 patients (24.5%) were considered as grade IV or V on admission. Aneurysm surgery within 48 hours after SAH was performed in 56.3% of these patients, 2% were operated between day 3 and 7 and 16.6% were operated after day 7. 25% did not undergo operation because of severe neurological deficit and brain damage. The overall outcome according to the Glasgow outcome scale in the surgically treated group was full recovery in 11.1%, moderate disability in 16.7%, severe disability in 47.2%, vegetative state in 2.8% and death in 22.2%. All patients in the not operated group died. Good and moderate outcome was mainly seen in patients grade IV, which justify an aggressive strategy. Severe disability was mainly attributed to primary brain damage, while vasospasm played a minor role. Improvement may only be achieved by early referral of SAH patients to neurosurgical centres.

Evaluation of collateral flow capacity in patients with vascular or tumorous lesions of the skull base by Doppler sonography.

In 12 patients with vascular or tumorous lesions of the skull base, the collateral flow capacity was examined by transcranial Doppler sonography and carotid compression studies. In four patients no cross flow mechanism was found, in two patients the test remained unclear, and in six patients the examination suggested a good collateral flow capacity. However, for this application of Doppler sonography no borderlines have yet been defined and thus interpretation is difficult. Intraoperative Doppler sonography was used in five patients and proved to be helpful for localisation of the internal carotid artery within skull base tumors.

Functional and morphological abnormalities in temporal lobe epilepsy: a comparison of interictal and ictal EEG, CT, MRI, SPECT and PET.

Ten patients suffering from drug-resistant complex partial seizures, with EEG abnormalities in the temporal region, were studied by means of non-invasive electrophysiological techniques (video-monitored, 16-channel, prolonged surface and sphenoidal EEG) as well as by imaging techniques (CT, MRI, SPECT and PET). Analysis of interictal and ictal EEG indicated the localization of epileptic activity in one side in eight cases. CT demonstrated focal abnormalities in three, SPECT in five unequivocally (in another four questionably, with the same lateralization as indicated by PET), MRI in eight, and PET in all cases. While only EEG provided specific diagnostic information, the focus definition was consistently good on PET images, poor on CT scans, and generally good but less consistent on MRI.

3-N-(2-[18F]-fluoroethyl)-spiperone: a novel ligand for cerebral dopamine receptor studies with pet.

3-N-(2-[18F]-fluoroethyl)-spiperone [( 18F]-FESP) was synthesized at high specific activity by condensation with 2-[18F]-fluoroethyltosylate (35 TBq/mmol). In vivo binding studies in baboons by positron emission tomography exhibited regio-selective uptake in the striatum which was saturable with the cold ligand and prevented by pretreatment with (+)-butaclamol. The pharmacokinetic behaviour, i.e. the absolute uptake in tissue and the striatum-to-cerebellum ratio, was very similar to that of methylspiperone. Analysis of the radioactivity in mouse brain after administration of [18F]-FESP indicated a high in-vivo stability (greater than 90% after 210 min in the striatum). Comparative distribution studies of other N-fluoroalkylspiperones in mice suggest that FESP and the N-fluoropropyl analogue are the most potent D2 receptor ligands.

PET, CT, and MR imaging in cerebrovascular disease.

Forty-five patients with cerebrovascular disease (single and multiple infarcts, intracerebral hemorrhages) were examined with X-ray CT, magnetic resonance (MR) imaging, and positron emission tomography (PET). In six patients with acute infarcts repeat measurements with all techniques were performed after 2 weeks. Magnetic resonance and PET were more sensitive in the detection of ischemic lesions than X-ray CT. With PET, functional disturbances could be demonstrated even in two cases where CT and MR were normal, while the latter techniques were superior in exactly localizing a lesion. Changes in lesion appearance with time were observed with all techniques, and the pathophysiologically important phenomena of hyperperfusion or hypermetabolism were documented in four infarcts with PET.

[MR of ischemic brain diseases. A comparison with CT, PET (18-fluorodeoxyglucose) and angiographic results]. / MR bei ischämischen Hirnerkrankungen. Ein Vergleich mit CT, PET (18Fluordeoxyglukose) und angiographischen Ergebnissen.

The results of MRI and CT in 55 patients with brain infarcts were compared; in 26 of these cases an additional PET examination was obtained in order to study the regional glucose utilisation. MRI was superior to CT, demonstrating 11% more of the infarcts, particularly during the first 24 hours, in small lesions confined to the grey or subcortical white matter and in infratentorial ischemic lesion. On the other hand, only CT was able to show fresh hemorrhage, although MRI was the method of choice to demonstrate old blood collections. To characterise the follow up of an infarct, CT and MRI were similar, except the marginal contrast enhancement sometimes demonstrated by CT studies between the 2nd and 4th week after stroke event. PET was inferior to show details because of its poorer spatial resolution, but anyhow had a high sensitivity and provided additional informations concerning secondary inactivations of brain areas not directly damaged. Additionally PET was able to demonstrate areas of anaerobic glycolysis and lesions of diminished glucose utilisation in TIAs. Small areas of gliosis in the white matter of the cerebral hemispheres were frequently found in patients with cerebro-vascular diseases; they were best shown by MRI, but do not correlate with the extent of vascular stenoses or occlusions, shown by angiography.