Immunohistochemically visualized localisation of gangliosides Glac2 (GD3) and Gtri2 (GD2) in cells of human intracranial tumors.

Antibodies against two major gangliosides detected in human brain and brain tumors--Glac2 (GD3) and Gtri2 (GD2)--were tested by immunohistochemistry in an unselected sample of intracranial tumors during the years 1986 through 1991. Two groups emerged as evaluable samples, namely gliomas of different grades and meningiomas. In a pilot series, it was shown that these gangliosides could be visualized in frozen sections of cells of gliomas and meningiomas (as well as neurinomas) and in some structures of the normal brain. It was however not possible in frozen sections to further analyze the cellular or subcellular expression pattern of the mentioned components and paraffin sections with conventional processing were only weakly and diffusely stained. A modified protocol therefore was created that replaced alcohol processing by acetone. With this protocol, interpretable results in paraffin sections were obtained. With this method, 133 single intracranial tumors were investigated as to their immunohistologically detectable ganglioside expression. The most consistent result was that the whole cytoplasm of highly fibrillary (gemistocytic) astrocytes in all grades of gliomas was stained by Gtri2 (GD2) and Glac2 (GD3) with high preponderance of Gtri2 (GD2) expression. In all meningiomas, Glac2 (GD3) had a higher expression than Gtri2. No constant pattern in the other entities emerged. By comparison with GFAP expression in gliomas and vimentin in meningiomas, the colocalisation of gangliosides and intermediary filament proteins is supposed.

Glycosphingolipid component profiles or human gliomas--correlation to survival time and histopathological malignancy grading.

BACKGROUND: Glycosphingolipids (GSL) are expressed on the surface of neuroectodermal cells. The correlation of a variety of distinct GSL with different primary brain tumors has been demonstrated. Three distinct GSL-component profiles (GSL-types I, II and III) of human gliomas have been defined by our group. The purpose of this study was to evaluate the correlation of the established GSL-types I-III with survival time and histopathological malignancy grading in 40 human gliomas. METHODS: Neutral and acidic GSL-component patterns, histopathological malignancy grade and survival time, and a number of other relevant variables were examined. Kaplan-Meier survival curves were analyzed with the log rank test. RESULTS: GSL-type I was expressed in 18 tumors (17 Glioblastoma multiforme (GBM) and 1 anaplastic astrocytoma (AA)). GSL-type II was expressed in 11 tumors (7 GBM, 3 AA, 1 low grade astrocytoma (LGA)). 10 patients presented with GSL-type III (3 GBM, 4 AA, 3 LGA). Kaplan Meier survival curves of GSL-types I-III differed significantly (p = 0.0231, log-rank-test). However, survival time correlated better to the WHO grades. Within a given malignancy grade, GSL-types gave additional informations about the proliferative properties. CONCLUSIONS: This is the first report of a correlation between survival time and human glioma neutral and acidic GSL-components. The results are in agreement with observations of other investigators. The analysis of GSL-type expression might give useful additional information about proliferative properties of human gliomas in a given malignancy grade. In particular, the early prediction of outcomes in anaplastic or low grade gliomas might be possible.

Basidiolipids from Agaricus are novel immune adjuvants.

The primary aim of the present study was to compare the immune adjuvanticity of two different groups of glycolipids, i.e., the newly discovered basidiolipids from Basidiomycete mushrooms (Bl-1, Bl-2, Bl-3, and Bl-4), and saponin fractions from Quillaja saponaria. The basidiolipids, though with differential effectiveness of the Bl-components, stimulated the expression of serum immune globulins in mice that recognized co-injected antigens, bovine serum albumin (BSA) or a keyhole-limpet hemocyanin-ganglioside Gfpt1 conjugate (KLH-Gfpt1), respectively. The immune adjuvanticity of the basidiolipids was comparable to that of acidic (QAS2, QAS5, QAS10), and novel neutral (QNS1, QNS2, QNS3) saponin compounds isolated and purified from Quillaja saponaria bark bulk material. Basidiolipids, as well as, the Q. saponin fractions were only marginally antigenic. MPL-A, by contrast, a comparable immune adjuvant, stimulated the expression of specific antibodies that recognized this glycophospholipid. Different from the Q. saponins with restricted toxicity, the basidiolipids displayed no toxic or hemolytic properties.

Novel glycoinositolphosphosphingolipids, basidiolipids, from Agaricus.

From the edible mushroom, the basidiomycetes Agaricus bisporus and Agaricus campestris, a novel carbohydrate-homologous series of four glyco-inositol-phospho-sphingolipids, designated basidiolipids, was isolated and the constituents purified. The chemical structures of the basidiolipids were elucidated to be: Manpbeta1-2inositol1-phospho-ceramide, Galpalpha-6[Fucpalpha-2]Galpbeta-6Manpbeta-2i nositol1-phospho-ceramide, Galpalpha-6Galpalpha-6[Fucpalpha-2]Galpbeta- 6Manpbeta-2inositol1-phospho-ceramide and Galpalpha-6Galpalpha-6Galpalpha-6[Fucpalpha-2] Galpbeta-6Manpbeta-2ino sitol1-phospho-ceramide. All four glycolipids contained a ceramide which was composed of phytosphingosine and predominantly alpha-hydroxy-behenic and alpha-hydroxy-lignoceric acid.

Continuous intrathecal baclofen infusion in severe spasticity after traumatic or hypoxic brain injury.

Severe spinal spasticity has been shown to be a good indication for continuous intrathecal baclofen infusion (CIBI), but there is only limited experience with this treatment in patients with supraspinal spasticity. Eighteen patients with severe spasticity from traumatic or hypoxic brain injury were treated with CIBI. In all patients spasticity could be reduced significantly. The mean Ashworth score was reduced from 4.5 to 2.33 and the mean Spasm frequency score from 2.16 to 0.94. This reduction of spasticity led to a marked pain reduction. Nursing, perineal care and mobilization became much easier. The complication rate was low. In this series we saw one infection in the pump pocket, one epileptic seizure after a bolus application of baclofen and one spinal catheter displacement. The results are similar to those reported from series of patients with spinal spasticity and correspond to the limited experience we have so far with supraspinal spasticity patients. To prevent limb contractures CIBI should be performed as soon as the patient is in a stable clinical condition after brain injury. Further prospective clinical trials will be necessary to obtain more experience with patients suffering from supraspinal spasticity.

The degradation of glycosphingolipids by air.

Exposure of glycosphingolipids to air irreversibly destroys the integrity of these lipids within a few hours. It was established that among the natural constituents of air, ozone, at commonly observed daytime levels, is responsible for the observed degradation. As one product of the reaction of glycosphingolipids with air, an aldehydic fragment containing the carbohydrate moiety was identified. This aldehydic fragment was identical to the one obtained by classical glycosphingolipid ozonolysis. Identical with the latter, the air-induced product is further fragmented by mild alkali treatment with concomitant liberation of the free reducing oligosaccharide. As a consequence of the alteration of glycosphingolipids by air, it was shown that the accuracy of methods of analysis of these glycoconjugates that depend on their physico-chemical integrity, e.g., by tlc-immune overlay, is severely influenced by their prior exposure to the atmosphere.

Endoscopic stereotaxy--an eight year's experience.

During the 10th meeting of the WSSFN in Maebashi in 1989, we discussed 'endoscopic stereotaxy', and presented our preliminary results. This technique was first designed to optimize stereotactic biopsy, but it proved to be effective for other neurosurgical indications as well, including endoscopic stereotactic evacuation of intraparenchymal and intraventricular space-occupying cysts, endoscopic stereotactic cystoventriculostomy, third ventriculostomy, evacuation of brain abscess and intracerebral hematoma, and retrieval of adherent or free-floating ventricular catheters. Our results with endoscopic stereotaxy in different indications are encouraging, compared to conventional microsurgical techniques and pure stereotactic techniques. From 1989 to 1997 we have performed more than 400 stereotactic endoscopic procedures. The mortality rate is below 1%, the operative morbidity is below 3%.

Endoscopic treatment of septated chronic subdural hematoma.

BACKGROUND: Chronic subdural hematomas are well delineated collections of fluid (blood) between the dura mater and the arachnoid space. Two types of encapsulated chronic subdural hematoma can be distinguished: the nonseptated and the septated form. The nonseptated form can be treated easily using the burrhole-drainage method, whereas treatment of septated chronic subdural hematoma remains a therapeutical problem. The main problem is the division of the hematoma by neomembranes into compartments, which hinder the efflux of the hematoma fluid through one or two burrholes. METHODS: Since 1991 we have operated on 14 patients with septated subdural hematoma using flexible steerable endoscopes through a burrhole approach. The flexible endoscopes are fixed and guided with the help of the Marburg Neuroendoscopy Fixation and Guiding System. For resection of neomembranes small microscissors or microforceps were used. This technique avoids blunt rupture of the membranes which may cause bleeding. A closed drainage system is applied temporarily to guarantee the efflux of the remaining hematoma. RESULTS: From January 1991 to May 1994, 14 patients with the septated variant of chronic subdural hematoma were operated on using the endoscopic technique. After the neuroendoscopic intervention 12 patients had a sufficient or complete hematoma evacuation. One patient had to be operated on a second time, and there was one postoperative subdural infection. Long term follow up of all patients shows no recurrence of the subdural hematoma. CONCLUSION: Treatment of membraneous septated CSH using an endoscopic operative technique combined with the application of a closed drainage system is a minimally invasive method and a therapeutic alternative to the craniostomy-membranectomy technique.

Effects of monophosphoryllipid-A on the immunization of mice with keyhole limpet hemocyanin- and muramyldipeptide-ganglioside Gfpt1 conjugates.

Since it was considered that an active immunization against ganglioside Gfpt1 (IV2Fuc-, II3NeuAc-Gg4Cer) expressed by human small cell lung cancer cells may be beneficial in the treatment of this neoplasm in humans, an optimal mode of vaccination in model mice was investigated. A novel Gfpt1-muramyldipeptide conjugate (Gfpt1-MDP) was synthesized. Its ganglioside carbohydrate-directed immunogenicity in mice as measured by serum antibody titers was comparable to that of the previously described Gfpt1-keyhole limpet hemocyanin conjugate (Gfpt1-KLH). Similar immunogenicity was displayed by free Gfpt1 in muramyldipeptide-phosphoethanolamine-containing phosphatidyl-choline, -serine (PC,PS) liposomes. Immunization with Gfpt1-vaccines in the presence of monophosphoryllipid A (MPL), in general, raised titers of anti-Gfpt1 antibodies effectively. Immunization with PC, PS-liposomes containing unconjugated Gfpt1 and MPL stimulated the highest titers observed, thereby effectively preventing tumor growth in Balbc nu/nu-mice challenged with human small cell lung cancer cells. However, there was a strong crossreaction of these and most other sera with the structurally related and widely distributed ganglioside Gtet1 (II3NeuAc-Gg4Cer). Only immunization with Gfpt1-KLH conjugate in the presence of MPL stimulated selectively high anti-Gfpt1 antibody titers showing comparably low crossreactivity to ganglioside Gtet1.

[Post-traumatic seizure prevention--results of a survey of 127 neurosurgery clinics]. / Posttraumatische Anfallsprophylaxe--Die Ergebnisse einer Umfrage unter 127 neurochirurgischen Kliniken.

Starting in November, 1993, until January, 1994, we performed a survey among 127 Neurosurgical Departments in Austria, Germany, and Switzerland concerning the practice of antiepileptic prophylaxis in head injured patients. Seventy seven percent of the 12-item multiple choice questionnaires were completed and returned. They indicate a variety of attitudes towards prophylaxis for seizures: in 12% of the responding institutions, antiepileptic prophylaxis is given to every brain trauma patient, in 36%, no prophylaxis is carried out. and in 52% some patients receive prophylaxis while others do not. Penetrating injuries, intracranial haemorrhages and electroencephalographic abnormalities were the most frequent reasons why prophylaxis was initiated. Phenytoin is by far the most popular drug, given usually for at least three months, and in most cases monitored by routine serum level observations. Nevertheless, about three out of four neurosurgeons conceded that a general renunciation of antiepileptic prophylaxis after brain trauma might be justified. There is no uniform way in which patients are informed about a possible risk of seizures, as it may be relevant, for instance, in respect of driving abilities.

Malignant transformation of benign gliomas during interstitial irradiation.

Interstitial curietherapy with 125-Iodine is an effective therapeutic option in the treatment of low grade gliomas. Four cases with astrocytoma grade II are presented, where tumour growth characteristics have changed to anaplasia during interstitial irradiation after a primary period of tumour regression. Anaplastic transformation could be due to a radiation effect or an insufficient therapeutic influence of interstitial irradiation on natural tumour progression of glioma growth due to genetic events.

Stereotactic endoscopic interventions in cystic brain lesions.

Stereotactic endoscopic techniques are extremely helpful in diagnosis and therapy of cystic intracerebral space occupying lesions. Acute space occupying lesions can be managed effectively and without major tissue traumatization. Up to now we have operated on more than 70 cystic intracerebral space occupying lesions with a stereotactic endoscopic technique. The main diagnoses were colloid cysts, cystic craniopharyngeoma, arachnoidal and pineal cysts. In must be stressed that in cystic anaplastic astrocytomas and glioblastomas as well as metastases only an acute inner cerebral decompression can be achieved by neuroendoscopic techniques in combination with the application of reservoir systems. In benign parenchymal or intraventricular cysts neuroendoscopic intervention is performed for definitive treatment. The results are overall encouraging. There was no operative mortality and operative morbidity was below 3%. Postoperative follow-up in patients with benign cysts showed no evidence of recurrence.

Serum immunoglobulins in Heymann's experimental nephritis modulate binding of properdin and factor-H to sulpho-glycosphingolipids II3SO3(-)-Gg3Cer and III3SO3(-)-,II3SO3(-)-Gg3Cer.

The nephropathic effects of Heymann's experimental nephrites involve autoallergic serum antibodies directed against rat kidney membrane constituents. In assessing the action of glycolipids as possible autoallergens in these conditions, it was found that heterologous and autologous Heymann's nephritis sera antibodies recognize that rat kidney sulphatides, II3SO3(-)-Gg3Cer (Stri1), and III3SO3(-)-,II3SO3(-)-Gg3Cer (Stri2). Two antibody populations in Heymann's sera, each reacting with only one of the two sulphatides, could be observed. It was further shown that human factor-H and properdin, pivotal regulators of the alternative pathway of complement activation, both bound to Stri2 in vitro. This binding of factor-H and properdin was differentially affected by affinity-purified anti-Stri2 antibodies of Heymann's nephritis sera. Whereas the interaction between factor-H and Stri2 was inhibited by the antibody, that of properdin was enhanced.

Specific immunization using keyhole limpet hemocyanin-ganglioside conjugates.

In a search for adjuvants of non-bacterial origin for immunization with ganglioside, we investigated whether chemical coupling to immune stimulatory protein could increase the immunogenicity of sialoglycosphingolipid. A novel method for the linkage of glycosphingolipids, including gangliosides, to protein was established. The procedure includes lysis of the sphingoid double bond by ozone, reduction of the ozonolysis product to the aldehyde, and coupling to amino groups, either directly by reductamination, or by conjugation via a long aliphatic chain dicarboxylic acid linker. Using this method, gangliosides Gfpt1 (IV2-Fuc-, II3NeuAc-Gg4Cer), Glac2 [II3(NeuAc)2-LacCer], and Gtet1 (II3NeuAc-Gg4Cer) were coupled to keyhole limpet hemocyanin (KLH), and the immunogenicity of the conjugates was tested. Immunization of mice with the KLH-ganglioside conjugates led in each case to the formation of IgG- and IgM antibodies that recognized the underivatized gangliosides, respectively. In contrast to this, mixtures of KLH and ganglioside proved ineffective for immunization. KLH-tumor-associated ganglioside conjugates may, therefore, be considered as possible vaccines in immune therapy of cancer.

[Predictors of treatment success after microsurgical operation of lumbar intervertebral disk displacement]. / Prädiktoren des Behandlungserfolges nach mikrochirurgischer Operation lumbaler Bandscheibenvorfälle.

As far as medical decision making is based on weighing up individual risks and chances of a certain patient receiving a certain treatment, some knowledge is required about signs and symptoms which are associated with a certain outcome: they are called risk factors, or predictive factors. In lumbar intervertebral disc surgery, the most frequent undesired effect of the treatment is unsuccessfulness. Reviewing the literature about risk factors for unsuccessfulness, one recognizes a lot of unconfirmed or even contradictory findings. This inconsistency can possibly be attributed to the common use of a very simplified, unidimensional definition of the target variable "success of treatment". That is why we performed a prospective observational trial on 109 patients in whom the success of lumbar intervertebral disc microsurgery was assessed after half a year using six different target variables. The rate of treatment success varied considerably, from 44% (when "return to previous occupation" served as the target variable) to 91% (with regard to "subjective contentedness"). Further target variables were intensity of sciatica, intensity of low back pain, activities of daily living, and postoperative paresis, giving intermediate success rates. We were able to identify some risk factors (for instance, duration of sick leave and of the recent pain episode, preoperative paresis, intensity of psychosomatic complaints), each of them being relevant to some of the target variables, but none of them associated with all of the target variables. We conclude that the multidimensional rating of treatment successes seems to promote risk research in multidimensional diseases.

[Results and reliability of stereotactic and endoscopic biopsies in brain tumors]. / Ergebnisse und Zuverlässigkeit stereotaktisch und endoskopisch gewonnener Probebiopsate bei Hirntumoren.

Stereotactic neurosurgery was the first "minimal invasive method" in the field of neurosurgery, later followed and partly replaced by endoscopic techniques. One reason for such an approach is sampling of small tissue probes for diagnosis, e.g. in brain tumours not accessible to open surgery. The appropriate method in the hands of the experienced is the "Quetsch" or smear technique. Its reliability is limited by the fact, that the "architectural" or "tissular" components of tumours lack in those purely cytological preparations. Tissue architecture however is crucial for the assessment of different grades in glial tumour progression. The grade of a glial tumour is the most critical information for the patient and the therapist; grading of the supratentorialf gliomas of the adult by means of cellular and tissue pleomorphism therefore forms the basis of Zülchs system of classification and grading of all intracranial tumours by comparison of postoperative survival. The resulting four grade system--slightly modified--is part of the old and new issue of the WHO classification of brain tumours. In order to specify the possibility of correct diagnosis and grading in probes gained by the minimal invasive techniques, we present results of three diagnostic approaches: First: We report results of a study performed during the last twelve years in which a diagnosis of smear preparations had been made on neurosurgical specimens prior to conventional handling. The "blind" cytological diagnosis was then compared with the final diagnosis of the tumour using light and electron microscopy and immunohistochemistry. Second: We report results and estimates of tissue probes gained by the so called sandwich technique in which the removal of material for cytological analysis is done stepwise. By doing so, material representative for different compartments of the neoplasm is obtained. This implies collaboration between neurosurgeon and neuropathologist not only during the time of stereotactic action but also in the planing period; the correct interpretation of the different compartments delivered by imaging methods in this context is essential. Third: We present selected cases of probe sampling under direct visual control by endoscopy. This method is especially useful for tumours bordering the ventricular system. Surface structures and cyst linings can be visualized directly if the endoscopist is familiar with normal and pathological tissue appearance. The specimen for analysis may therefore be taken from the most relevant tumour region and the sandwich technic which means tissue damaging in multiple localisations can be partly or fully avoided.(ABSTRACT TRUNCATED AT 400 WORDS)

[Intracranial pressure in sleep apnea, hydrocephalus and congenital hemangioma. A case report]. / Intrakranieller Druck bei Schlafapnoe, Hydrozephalus und kongenitalen Hämangiomen. Ein Fallbericht.

A patient with obstructive sleep-apnea-syndrome and congenital temporal and cervical hemangiomas developed severe headache under nasal BiPAP ventilation. Internal hydrocephalus was diagnosed by CCT and MRI and rise of intracranial pressure (ICP) under artificial ventilation was supposed. Polysomnography, ICP-measurement with a ventricular catheter and resistance to outflow-measurement were used to clarify differential diagnosis. During periods of apnea ICP was raised severely with a maximum in REM-sleep. With nasal ventilation no apnea was observed and ICP was normalized. Resistance to outflow was normal. A disturbance of CSF-dynamics or CSF-absorption leading to the patient's headache could be excluded. Duplex-sonography and cerebral angiography did not provide further information. After exclusion of other causes artificial respiration dependent swelling of the subcutaneous temporal and cervical hemangiomas was the most likely cause triggering the headache. A sufficient therapy however was not yet available. Probably the patient suffers from an abortive form of a Sturge-Weber-Krabbe-Dimitri-Syndrome.

Glycosphingolipid component profiles of human gliomas correlate with histological tumour types: analysis of inter-individual and tumour-regional distribution.

Three types of glycosphingolipid (GSL) component profiles have been established for human intracranial gliomas. GSL-type I shows only Glac- and lacto-series-sialoglycolipids. Type II consist of Glac- and Gtri-gangliosides, whereas only GSL-type III contains sulphatide and, as a major neutral glycolipid, galactocerebroside, besides gangliosides of the Glac-, Gtri-, and Gtet-families. Whole gliomas of malignancy grading I/II, III and IV, display GSL-Types III, II, and I, respectively. Thus, the GSL component distribution of the samples taken after surgery from three individual gliomas and two biopsies correlate closely with the general diagnosis of these tumours. Arthrobacter ureafaciens sialidase was used for the characterization of gangliosides. GSL-type analysis of multiple regional samples, taken from necropsy and biopsy, were determined by microanalysis of microscopic cryostat section, and shown to be in good agreement with their histology. The results validate the relevance of tumour ganglioside analysis for the characterization and diagnosis of gliomas.

Peri-operative changes of cellular and humoral components of immunity with brain tumour surgery.

Nosocomial infections, which are not uncommon in neurosurgical intensive care medicine, may possibly be favoured by an impairment of immunological competence of the patient. In a prospective observational trial, we investigated several parameters of cellular and humoral immunity in 32 patients before and after resection of an intracranial tumour. We quantified the effects of operative procedure, dexamethasone pretreatment, and tumour type. Dexamethasone alone causes an increase of neutrophilic granulocyte count and monocytes, whereas IgG and eosinophilic granulocytes decrease as well as lymphocytes. CD4+ T lymphocytes (T helper cells) and CD8+ T lymphocytes (T cytotoxic/suppressor cells) were more severely affected than B lymphocytes. Dexamethasone and operation in combination act synergistically on T lymphocytes and IgG, while no synergism is obvious in other clinical test parameters. The skin sensitivity reaction was depressed accordingly. With intracerebral tumours (gliomas WHO grades II to IV), levels of T helper cells and eosinophilic granulocytes were lower, and levels of IgM and neutrophilic granulocytes were higher than with benign extracerebral neoplasms. Postoperative nosocomial infections of the lower respiratory tract occurred almost exclusively in patients subject to severe depression of T helper cells.

Minimally invasive endoscopic neurosurgery--a survey.

In 1989 we introduced "endoscopic stereotaxy" as a new operative procedure into neurosurgery. This technique was first scheduled to optimize stereotactic biopsy. In its further development it proved to be effective for other indications. We choose the term "Minimal Invasive (Endoscopic) Neurosurgery (MIEN)" for these interventions. Minimal invasive endoscopic techniques are applied preferably for diagnostic and therapeutic interventions on preformed or pathological cavities of the central nervous system. The indications are, endoscopic-stereotactic biopsy of space-occupying lesions, ventriculoscopy and endoscopic ventriculostomy in diagnosis and treatment of hydrocephalus, endoscopic evacuation of cystic space occupying lesions, endoscopic evacuation of intracerebral haematoma, endoscopic evacuation of septated chronic subdural haematoma, endoscopic evacuation of subacute or chronic brain abscesses, endocavitary syringostomy. Our results with minimal invasive endoscopic interventions for different indications are encouraging when compared to conventional microsurgical techniques. We have performed more than 300 minimal invasive endoscopic interventions. The mortality rate was below 1%, the operative morbidity was below 2%.