Diagnostic Performance of Whole-Body Ultra-Low-Dose CT for Detection of Mechanical Ventriculoperitoneal Shunt Complications: A Retrospective Analysis.

BACKGROUND AND PURPOSE: Radiographic shunt series are still the imaging technique of choice for radiologic evaluation of VP-shunt complications. Radiographic shunt series are associated with high radiation exposure and have a low diagnostic performance. Our aim was to investigate the diagnostic performance of whole-body ultra-low-dose CT for detecting mechanical ventriculoperitoneal shunt complications. MATERIALS AND METHODS: This retrospective study included 186 patients (mean age, 54.8 years) who underwent whole-body ultra-low-dose CT (100 kV[peak]; reference, 10 mAs). Two radiologists reviewed the images for the presence of ventriculoperitoneal shunt complications, image quality, and diagnostic confidence. On a 5-point Likert scale, readers scored image quality and diagnostic confidence (1 = very low, 5 = very high). Sensitivity, specificity, positive predictive value, and negative predictive value were calculated. Radiation dose estimation of whole-body ultra-low-dose CT was calculated and compared with the radiation dose of a radiographic shunt series. RESULTS: 34 patients positive for VP-shunt complications were correctly identified on whole-body ultra-low-dose CT by both readers. No false-positive or -negative cases were recorded by any of the readers, yielding a sensitivity of 100% (95% CI, 87.3%-100%), a specificity of 100% (95% CI, 96.9%-100%), and perfect agreement (κ = 1). Positive and negative predictive values were high at 100%. Shunt-specific image quality and diagnostic confidence were very high (median score, 5; range, 5-5). Interobserver agreement was substantial for image quality (κ = 0.73) and diagnostic confidence (κ = 0.78). The mean radiation dose of whole-body ultra-low-dose CT was significantly lower than the radiation dose of a conventional radiographic shunt series (0.67 [SD, 0.4] mSv versus 1.57 [SD, 0.6] mSv; 95% CI, 0.79-1.0 mSv; P < .001). CONCLUSIONS: Whole-body ultra-low-dose CT allows detection of ventriculoperitoneal shunt complications with excellent diagnostic accuracy and diagnostic confidence. With concomitant radiation dose reduction on contemporary CT scanners, whole-body ultra-low-dose CT should be considered an alternative to the radiographic shunt series.

Value of ultra-high field MRI in patients with suspected focal epilepsy and negative 3 T MRI (EpiUltraStudy): protocol for a prospective, longitudinal therapeutic study.

PURPOSE: Resective epilepsy surgery is a well-established, evidence-based treatment option in patients with drug-resistant focal epilepsy. A major predictive factor of good surgical outcome is visualization and delineation of a potential epileptogenic lesion by MRI. However, frequently, these lesions are subtle and may escape detection by conventional MRI (≤ 3 T). METHODS: We present the EpiUltraStudy protocol to address the hypothesis that application of ultra-high field (UHF) MRI increases the rate of detection of structural lesions and functional brain aberrances in patients with drug-resistant focal epilepsy who are candidates for resective epilepsy surgery. Additionally, therapeutic gain will be addressed, testing whether increased lesion detection and tailored resections result in higher rates of seizure freedom 1 year after epilepsy surgery. Sixty patients enroll the study according to the following inclusion criteria: aged ≥ 12 years, diagnosed with drug-resistant focal epilepsy with a suspected epileptogenic focus, negative conventional 3 T MRI during pre-surgical work-up. RESULTS: All patients will be evaluated by 7 T MRI; ten patients will undergo an additional 9.4 T MRI exam. Images will be evaluated independently by two neuroradiologists and a neurologist or neurosurgeon. Clinical and UHF MRI will be discussed in the multidisciplinary epilepsy surgery conference. Demographic and epilepsy characteristics, along with postoperative seizure outcome and histopathological evaluation, will be recorded. CONCLUSION: This protocol was reviewed and approved by the local Institutional Review Board and complies with the Declaration of Helsinki and principles of Good Clinical Practice. Results will be submitted to international peer-reviewed journals and presented at international conferences. TRIAL REGISTRATION NUMBER: www.trialregister.nl : NTR7536.

Decreased angiogenesis as a possible pathomechanism in cervical degenerative myelopathy.

Endogenous immune mediated reactions of inflammation and angiogenesis are components of the spinal cord injury in patients with degenerative cervical myelopathy (DCM). The aim of this study was to identify alteration of certain mediators participating in angiogenetic and inflammatory reactions in patients with DCM. A consecutive series of 42 patients with DCM and indication for surgical decompression were enrolled for the study. 28 DCM patients were included, as CSF samples were taken preoperatively. We enrolled 42 patients requiring surgery for a thoracic abdominal aortic aneurysm (TAAA) as neurologically healthy controls. In 38 TAAA patients, CSF samples were taken prior to surgery and thus included. We evaluated the neurological status of patients and controls prior to surgery including NDI and mJOA. Protein-concentrations of factors with a crucial role in inflammation and angiogenesis were measured in CSF via ELISA testing (pg/ml): Angiopoietin 2, VEGF-A and C, RANTES, IL 1 beta and IL 8. Additionally, evaluated the status of the blood-spinal cord barrier (BSCB) by Reibers´diagnostic in all participants. Groups evidently differed in their neurological status (mJOA: DCM 10.1 ± 3.3, TAAA 17.3 ± 1.2, p < .001; NDI: DCM 47.4 ± 19.7, TAAA 5.3 ± 8.6, p < .001). There were no particular differences in age and gender distribution. However, we detected statistically significant differences in concentrations of mediators between the groups: Angiopoietin 2 (DCM 267.1.4 ± 81.9, TAAA 408.6 ± 177.1, p < .001) and VEGF C (DCM 152.2 ± 96.1, TAAA 222.4 ± 140.3, p = .04). DCM patients presented a mild to moderate BSCB disruption, controls had no signs of impairment. In patients with DCM, we measured decreased concentrations of angiogenic mediators. These results correspond to findings of immune mediated secondary harm in acute spinal cord injury. Reduced angiogenic activity could be a relevant part of the pathogenesis of DCM and secondary harm to the spinal cord.

Cervical spondylotic myelopathy: Changes of fractional anisotropy in the spinal cord and magnetic resonance spectroscopy of the primary motor cortex in relation to clinical symptoms and their duration.

OBJECTIVE: To determine the changes in fractional anisotropy (FA) at the proximal spinal cord and in magnetic resonance spectroscopy (MRS) of the precentral gyrus in patients with cervical spondylotic myelopathy (CSM) with respect to clinical symptoms and their duration. MATERIAL AND METHODS: 20 patients with CSM (7 female; mean age 64.6 ± 10.5 years) and 18 age/sex matched healthy controls (9 female; mean age 63.5 ± 6.6 years) were prospectively included. Clinical data (modified Japanese Orthopaedic Association Score (mJOA) and Neck Disability Index (NDI)) and 3T MR measurements including DTI at the spinal cord (level C2/3) with FA and MRS of the left and right precentral gyrus were taken. Clinical correlations and regression analyses were performed. RESULTS: Mean clinical scores of patients were significantly different to controls (mJOA; CSM: 10.2 ± 2.9; controls: 18.0 ± 0.0, p < 0.001; NDI; CSM: 41.4±23.5; controls: 4.4±6.6, p<0.001); FA was significantly lower in patients (CSM: 0.645 ± 0.067; controls: 0.699 ± 0.037, p = 0.005). MRS showed significantly lower metabolite concentrations between both groups: creatine (Cr) (CSM: 46.46±7.64; controls: 51.36±5.76, p = 0.03) and N-acetylaspartate (NAA) (CSM: 93.94±19.22; controls: 107.24±20.20, p = 0.05). Duration of symptoms ≤6 months was associated with increased myo-inositol (Ins) (61.58±17.76; 44.44±10.79; p = 0.02) and Ins/Cr ratio (1.36±0.47; 0.96±0.18; p = 0.014) compared to symptoms >6 months. CONCLUSION: Metabolic profiles of the precentral gyrus and FA in the uppermost spinal cord differ significantly between patients and healthy controls. Ins, thought to be a marker of endogenous neuroinflammatory response, is high in the early course of CSM and normalizes over time.

Spontaneous Elevation of Blood Pressure After SAH: An Epiphenomenon of Disease Severity and Demand, But Not a Surrogate for Outcome?

BACKGROUND: Spontaneous blood pressure increase is frequently observed after aneurysmal subarachnoid hemorrhage (aSAH). These episodes of spontaneous blood pressure alterations are usually tolerated under the assumption of an endogenous response to maintain cerebral perfusion. The relevance of blood pressure variability and its relationship to disease severity and outcome, however, remain obscure. METHODS: A total of 115 consecutive patients with aSAH were included for this retrospective analysis of a continuously collected data pool. Demographics, initial clinical severity of aSAH (HH°, mFS), treatment modality, clinical course, and outcome (development of DCI, cerebral infarction, and GOS after 3 months) were recorded. Hemodynamic information-recorded automatically with a frequency of 1/15 min-was analyzed for spontaneous blood pressure increase (SBI) and endogenous persistent hypertension (EPH) after exclusion of iatrogenic factors and relevant co-medication. Subgroup analysis included stratification for day 0-3, 4-14, and 14-21. RESULTS: SBI and EPH incidence varied from 17 to 84% depending on detection threshold (15-35 mmHg) and time period under scrutiny. Incidence of blood pressure increase correlated with disease severity upon admission (p < 0.05), but the anticipated association with outcome was not observed. SBI and EPH were more likely to occur between day 4 and 14 (p < 0.001), but only early occurrence (day 0-3) was associated with higher incidence of DCI (p < 0.05). Persistent blood pressure elevation between day 4 and 21 was associated with fewer DCI. However, no influence of spontaneous upregulation on clinical outcome after three months was observed. CONCLUSIONS: Spontaneous hemodynamic upregulation is a frequent phenomenon after aSAH. Our data support the hypothesis that spontaneous blood pressure alterations reflect an endogenous, demand-driven response correlating with disease severity. Early alterations may indicate an aggravated clinical course, while later upregulation in particular-if permitted-does not translate into a higher risk of unfavorable outcome.

Delayed cerebral ischaemia prevention and treatment after aneurysmal subarachnoid haemorrhage: a systematic review.

UNLABELLED: : The leading cause of morbidity and mortality after surviving the rupture of an intracranial aneurysm is delayed cerebral ischaemia (DCI). We present an update of recent literature on the current status of prevention and treatment strategies for DCI after aneurysmal subarachnoid haemorrhage. A systematic literature search of three databases (PubMed, ISI Web of Science, and Embase) was performed. Human clinical trials assessing treatment strategies, published in the last 5 yr, were included based on full-text analysis. Study data were extracted using tables depicting study type, sample size, and outcome variables. We identified 49 studies meeting our inclusion criteria. Clazosentan, magnesium, and simvastatin have been tested in large high-quality trials but failed to show a beneficial effect. Cilostazol, eicosapentaenoic acid, erythropoietin, heparin, and methylprednisolone yield promising results in smaller, non-randomized or retrospective studies and warrant further investigation. Topical application of nicardipine via implants after clipping has been shown to reduce clinical and angiographic vasospasm. Methods to improve subarachnoid blood clearance have been established, but their effect on outcome remains unclear. Haemodynamic management of DCI is evolving towards euvolaemic hypertension. Endovascular rescue therapies, such as percutaneous transluminal balloon angioplasty and intra-arterial spasmolysis, are able to resolve angiographic vasospasm, but their effect on outcome needs to be proved. Many novel therapies for preventing and treating DCI after aneurysmal subarachnoid haemorrhage have been assessed, with variable results. Limitations of the study designs often preclude definite statements. Current evidence does not support prophylactic use of clazosentan, magnesium, or simvastatin. Many strategies remain to be tested in larger randomized controlled trials. CLINICAL TRIAL REGISTRATION: This systematic review was registered in the international prospective register of systematic reviews. PROSPERO: CRD42015019817.

The bigger, the better? About the size of decompressive hemicraniectomies.

INTRODUCTION: Decompressive hemicraniectomy (DHC) is a treatment option in refractory ICP elevation and malignant infarction. A minimum diameter of 12 cm has been widely accepted as mandatory for effective decompression for ICP control. Complete hemispheric exposure is frequently advocated to further reduce the risk of parenchymal shear stress, hemorrhage and swelling. At the same time, superior efficacy and comparable risk profile of a more extensive decompression have yet to be established. MATERIAL AND METHODS: We reviewed 74 patients with comprehensive clinical data sets undergoing DHC from 2008 to 2013 at our institution. With a minimum threshold of 12 cm in AP diameter being observed in all cases, patients were grouped according to the absolute size of maximum AP diameter (<18 cm, ≥ 18 cm) and surface estimate (<180 cm(2), ≥ 180 cm(2)). Surgical technique, efficacy of ICP control, surgical complications and early clinical course were recorded. RESULTS: Baseline demographics were comparable in both groups. Surgery was effective in relieving or preventing intracranial hypertension in all patients, irrespective of craniectomy size. With smaller craniectomies, immediate surgical and secondary complications such as parenchymal herniation, hemorrhage, or swelling did not occur more frequently. CONCLUSION: Due to the heterogeneity of underlying disease, a conclusion as to effect of craniectomy size on long-term outcome cannot be made based on this study. However, if the obligatory lower threshold of 12 cm for DHC size and decompression to the temporal base are observed, a smaller craniectomy is equally effective in relieving intracranial hypertension. While not inadvertently associated with a more favorable surgical risk profile, it does not increase the risk for early secondary complications such as parenchymal shear stress, hemorrhage and swelling.

[Current treatment strategies for spondylodiscitis in surgical clinics in Germany]. / Aktuelle Behandlungsstrategien der Spondylodiszitis in deutschen Akutkliniken.

BACKGROUND: Spondylodiscitis is a rare disease which is associated with high mortality. No guidelines for treatment exist and the available studies are not homogeneous. Attempts have been made in recent years to structure therapy using algorithms. Early recognition of the disease is above all important for its later outcome. Therapy takes place in not only orthopaedic/trauma surgery clinics but also in neurosurgical clinics. MATERIAL AND METHOD: We sent an online survey on this subject to orthopaedic clinics, trauma surgery and neurosurgery clinics in Germany. The aim was to ascertain current care strategies in Germany. A further objective was to elicit differences between the specialist fields. RESULTS: A total of 164 clinics responded to the survey. The response rate was 16% of the orthopaedic/trauma surgery clinics and 32% of the neurosurgical clinics. Differences between the two specialist fields can be found particularly in the use of systemic and local antibiotics, in the choice of surgical access to the thoracic spine and the lumbar spine and in post-operative imaging. In both specialist fields, patients with neurological dysfunctions are treated primarily in clinics with high case numbers. In terms of surgery, 2/3 of the responding clinics choose a one-stage operative treatment. Minimally invasive procedures and the use of cages are widespread. The participants estimate that, on the whole, a better outcome and higher patient satisfaction tend to exist after operative treatment. CONCLUSIONS: The lack of homogeneity regarding treatment strategies which is indicated here clearly shows the need for therapy guidelines as an aid to orientation. This will be a challenge for the future due to the low incidence and the situation regarding currently available studies.

Analysing the response in R2* relaxation rate of intracranial tumours to hyperoxic and hypercapnic respiratory challenges: initial results.

OBJECTIVE: To investigate the response in R2* relaxation rate of human intracranial tumours during hyperoxic and hypercapnic respiratory challenges. METHODS: In seven patients with different intracranial tumours, cerebral R2* changes during carbogen and CO(2)/air inhalation were monitored at 3 T using a dynamic multigradient-echo sequence of high temporal and spatial resolution. The R2* time series of each voxel was tested for significant change. Regions of interest were analysed with respect to response amplitude and velocity. RESULTS: The tumours showed heterogeneous R2* responses with large interindividual variability. In the 'contrast-enhancing' area of five patients and in the 'non-tumoral' tissue most voxels showed a decrease in R2* for carbogen. For the 'contrast-enhancing' area of two patients hardly any responses were found. In areas of 'necrosis' and perifocal 'oedema' typically voxels with R2* increase and no response were found for both gases. For tissue responding to CO(2)/air, the R2* changes were of the same order of magnitude as those for carbogen. The response kinetic was generally attenuated in tumoral tissue. CONCLUSION: The spatially resolved determination of R2* changes reveals the individual heterogeneous response characteristic of intracranial human tumours during hyperoxic and hypercapnic respiratory challenges.

Gated multidetector computed tomography. A technique to reduce intracranial aneurysm clip and coil artifacts.

BACKGROUND AND PURPOSE: Streak artifacts caused by aneurysm clips and coils impede image quality in multidetector computed tomography (MDCT). The authors propose a technique to minimize these artifacts by gated data reconstruction and shifting the reconstruction window. PATIENTS AND METHODS: Intracranial CT angiograms were acquired in the follow-up of six patients with clipped and coiled intracranial aneurysms, respectively. Images were reconstructed from four consecutive 45 degrees rotated segments with an acquisition time of 52.5 ms/segment. Data acquisition was gated via an external pacemaker cable-connected to the scanner. RESULTS: Artifact orientation could be rotated by shifting the reconstruction window and interesting vessel segments visualized without disturbing streak artifacts. This allowed to assess the posterior communicating artery origin in two cases and a middle cerebral artery aneurysm remnant in another case, respectively. However, due to a higher noise interesting vessel segments were not adjustable in another three patients. CONCLUSION: Gated MDCT is a promising technique to reduce the amount and to change the position of artifacts induced by clips or coils.

Incidental pituicytoma after accidental head trauma--case report and review of literature.

OBJECTIVE: We report on a patient with pituicytoma, i.e. a rare neoplasm of the neurohypophysis, with unusual anamnestic manifestation. CASE MATERIAL: After a car accident, the patient suffered from severe persisting headaches. Diagnostic procedures revealed a minor visual impairment and restriction of the gonado- and somatotropic pituitary axis. MRI showed an architecturally solid, well demarcated and homogenous suprasellar lesion. Due to the challenging location of the lesion with a small intrasellar mass and larger suprasellar part within the hypophyseal stalk, a subtotal resection was carried out to save the pituitary function and for neuropathological assessment comprising numerous stainings and immunohistochemical reactions. We observed a highly differentiated, low proliferative, rather cellular and in individual parts moderately pleomorphic tumor with cells arranged in storiform or whorled patterns, that strongly expressed S-100 protein, microtubulus-associated protein 2 (MAP2) and vimentin. Postoperative visual field testing was inconspicuous, but pituitary malfunction was persistent. With respect to the accidental discovery of this pituicytoma, it remains unresolved whether the persisting headache was due solely to the head trauma or was additive with the effects of the pituicytoma. CONCLUSION: To date less than 30 bona fide examples have been described and typically present symptoms due to mass effects such as visual disturbances, hypopituitarism as well as interference with hypothalamic dopamine release, resulting in subsequent hyperprolactinemia accompanied by decreased libido and amenorrhea in females. These neoplasms represent an important differential diagnosis with respect to suprasellar lesions and a clinical and neuropathological challenge.

Epilepsy surgery for insular lesions.

OBJECTIVE: Due to the proximity of eloquent areas of the brain, the surgical treatment of insular lesions causing refractory epilepsy is considered difficult. We report here on our experience in this field. METHODS: We identified 24 patients (age: 1-62 years, mean 27) who underwent epilepsy surgery for an insular lesion from the epilepsy surgery data bank. We analyzed the preoperative diagnostics, surgical strategy and postoperative follow-up (duration: 12-168 months, mean 37.5) for functional morbidity and seizure outcome. RESULTS: Eight patients had strictly insular lesions while, in 16 cases, the lesion extended into the frontal (n=3) or temporal (n=8) lobe, or was multilobar (n=5). Sixteen resections (66.7%) were right-sided. Six patients required invasive EEG with implanted electrodes, while three had the aid of intraoperative electrocorticography. In 12 patients, continuous electrophysiological monitoring was used intraoperatively (phase reversal, motor evoked potentials) and, in seven, neuronavigation. In seven patients, only subtotal resection of the insular lesion was possible due to involvement of eloquent areas, and two patients required repeat surgery to complete the resection. Thirteen patients had glial/glioneural tumours (WHO grades I-III), 11 from non-neoplastic lesions. Postoperatively, two patients (8.3%) had a transient neurological deficit (hemiparesis and dysphasia, respectively). One patient had permanent hemihypaesthesia, another had permanent deterioration of preexistent hemiparesis and two had hemianopia as calculated deficit (16.6% rate of mild permanent morbidity). According to the International League against Epilepsy (ILAE) classification, 15 patients were totally seizure-free (62.5%, ILAE 1) and 79.2% had a satisfactory seizure outcome (ILAE 1-3). CONCLUSION: In selected patients, an individually tailored lesionectomy of insular lesions can be performed, with acceptable safety, to provide a high rate of satisfactory seizure relief. Indeed, even subtotal resection can result in effective seizure control.

Causes, presentation and outcome of lesional adult onset mediotemporal lobe epilepsy.

BACKGROUND AND AIMS: Mediotemporal lobe (MTL) epilepsy (MTLE) is particularly frequent among human localisation related epilepsies. MTLE usually starts before adulthood and is most frequently associated with hippocampal sclerosis (HS). Here, aetiologies, disease courses and outcomes of adult onset MTLE patients treated at this tertiary epilepsy centre are studied. METHODS: We collected all patients studied between January 1999 and December 2005 fulfilling the following criteria: (1) MTLE manifestation at age > 20 years; (2) time between disease manifestation and assessment < or = 6 years; (3) MTL lesion on brain MRI; and (4) neuropsychological test battery applied. The diagnoses were classified and paraclinical data, neuropsychological performances, and seizure and memory outcomes were documented. RESULTS: Diagnoses in the 84 patients (mean age 42 years at MTLE onset) were: limbic encephalitis (LE), n = 23 (27%); HS (unrelated to inflammation), n = 18 (22%); tumours I/II(o), n = 12 (14%); amygdala lesions (increased volume and T2/FLAIR signal), n = 11 (13%); and other, n = 20 (24%). Visible MTL affection was frequently bilateral in patients with LE (57%) and HS (22%). These groups also showed the poorest memory performance. Patients with amygdala lesions were the oldest (mean age 52 years); their lesions were in part immune mediated and in part probably dysplastic. Treatment dependent seizure outcomes were similar to published data without restriction to adult onset cases. Under conservative therapy, memory performance remained stable in patients with HS but improved in a proportion of patients with LE. CONCLUSIONS: The data suggest that LE is a common and a previously underestimated cause of MTLE in this age group. Its prognosis is variable. Amygdala lesions, also, are in part encephalitic in nature.

Insular lesionectomy for refractory epilepsy: management and outcome.

Surgical treatment of deep-seated insular lesions causing refractory epilepsy is thought to be difficult due to the complicated accessibility and close proximity of eloquent areas. Here we report our experience with insular lesionectomies. Twenty-four patients (range 1-62 years, mean 27) who underwent epilepsy-surgery for a lesion involving the insular region, were identified from the epilepsy surgery data bank. We analysed pre-surgical diagnostics, surgical strategy and postoperative follow up concerning functional morbidity and seizure outcome (range 12-168 months, mean 37.5). Eight patients had pure insular lesions, in 16 cases the lesion extended either to the frontal (n = 3) or temporal lobe (n = 8) or was multilobar (n = 5). Sixteen resections (66.7%) were done on the right side. Six patients required invasive EEG-recording, three patients received intra-operative electrocorticography. In seven patients only subtotal resection of the insular lesion was possible due to involvement of eloquent areas. Thirteen patients suffered from glial/glioneural tumours (WHO grades I-III), 11 from non-neoplastic lesions. Postoperatively, one patient had a hemihypesthesia and one patient had a deterioration of a pre-existing hemiparesis; two patients had a hemianopia as calculated deficit (mild permanent morbidity 16.6%). According to the ILAE-classification, 15 patients were completely seizure free (62.5%, ILAE 1). Around 79.2% had satisfactory seizure outcome (ILAE 1-3). In selected patients an individually tailored lesionectomy of insular lesions can be performed, which is acceptably safe and provides a high rate of satisfactory seizure relief. Even subtotal resection can result in good seizure control.

Cranioplasty for large skull defects with PMMA (Polymethylmethacrylate) or Tutoplast processed autogenic bone grafts.

OBJECTIVE: Aim of the study was a comparison of cranioplasty using the Tutoplast technology for autogenic bone processing and conventional polymethylmethacrylate (PMMA) calvarial re- construction. PATIENTS AND METHODS: A retrospective analysis was carried out in a consecutive series of 61 plastic reconstructions for skull defects, the largest measuring more than 12 cm. Cranioplasty was either performed with PMMA or with the patient's own bone graft which had been recycled using the Tutoplast process. RESULTS: 36 patients with a mean age of 44 (range 10-68) years underwent freehand PMMA cranioplasty following craniectomy for increased intracranial pressure (19 patients, 52.8%), infection (15 patients, 41.7%), or traumatic bone destruction (2 patients, 5.6%). Bilateral procedures were performed in 10 patients (27.8%). Mean follow-up was 44 months. Four patients (11.1%) died, 14 (38.9%) remained severely disabled, and 18 (50%) made a satisfactory recovery. Two patients (5.6%) had PMMA-related complications and required removal. 26 patients exhibited at least satisfactory cosmetic results (83.9%), in 5 patients the results were not satisfactory (16.1%) and in 5 the results are unknown. Twenty-five patients with a mean age of 42 (range 2-68) years received Tutoplast processed autografts following craniectomy for elevated intracranial pressure. Bilateral procedures were performed in 3 patients (12%). Mean follow-up was 15 months. One patient (4%) died, 18 (72%) remained severely disabled, and 6 (24%) made a satisfactory recovery. All patients had satisfactory cosmetic results, but 2 patients (8.3%) required removal at a later stage, one due to infection (4.2%) and one for bone resorption (4.2%). In the 18 patients with follow-up >0.5 years significant resorption occurred in all 5 children and adolescents (100%) and in two adult patients (15.4%). CONCLUSION: Cosmetic results were more satisfactory with Tutoplast processed autografts, and the operating time for unilateral surgery was shorter. Complication rates were similar. Resorption occurred in all children and adolescents, but was rare in adults. Thus, Tutoplast processed autogenic bone grafts can be a reasonable alternative to other methods of cranioplasty in adult patients with large craniotomy defects. Cranioplasty in children and adolescents remains an unsolved problem.

Focal cortical dysplasia: long term seizure outcome after surgical treatment.

BACKGROUND: Studies of long term outcome after epilepsy surgery for cortical malformations are rare. In this study, we report our experience with surgical treatment and year to year long term outcome for a subgroup of patients with focal cortical dysplasia (FCD). METHODS: We retrospectively analysed the records of 49 patients (females n = 26; males n = 23; mean age 25 (11) years) with a mean duration of epilepsy of 18 years (range 1-45). Preoperative MRI, histological results based on the Palmini classification and clinical year to year follow-up according to the International League Against Epilepsy (ILAE) classification were available in all patients. RESULTS: 98% of patients had a lesion on preoperative MRI. In addition to lobectomy (n = 9) or lesionectomy (n = 40), 14 patients had multiple subpial transections of the eloquent cortex. The resected tissue was classified as FCD type II b in 41 cases with an extratemporal (88%) and FCD type II a in 8 cases with a temporal localisation (100%). After a mean follow-up of 8.1 (4.5) years, 37 patients (76%) were seizure free, a subgroup of 23 patients (47%) had been completely seizure free since surgery (ILAE class 1a) and 4 patients (8%) had only auras (ILAE class 2). Over a 10 year follow-up, the proportion of satisfactory outcomes decreased, mainly within the first 3 years. During long term follow-up, 48% stopped antiepileptic drug treatment, 34% received a driver's license and 57% found a job or training. CONCLUSION: Surgical treatment of epilepsy with FCD is not only successful in the short term but also has a satisfying long term outcome which remains constant after 3 years of follow-up but is not associated with better employment status or improvement in daily living.

Present practice and perspective of evaluation and surgery for temporal lobe epilepsy.

Surgery for temporal lobe epilepsy refractory to medical treatment is a promising treatment option. After a short overview of historical developments in this field, we describe the present practice of presurgical evaluation and resection strategies as practiced at our institution and review the corresponding publications from other centers. We will be trying to outline major future developments for the surgical therapy of temporal lobe epilepsy based on present trends.

Correlation of health-related quality of life after surgery for mesial temporal lobe epilepsy with two seizure outcome scales.

PURPOSE: The objective of this study was to correlate health-related quality of life (HRQOL) after surgery for mesial temporal lobe epilepsy, as revealed by a postoperative screening tool, to different modalities of seizure outcome classification (Engel, International League Against Epilepsy (ILAE)). METHOD: One hundred twenty-eight of one hundred forty consecutive patients returned a HRQOL questionnaire at a mean of 36 months after selective amygdalohippocampectomy. Patients answered in two ways: with an absolute estimation (values 1-4) and with a self-rated relative change (-1, 0, +1) after surgery. RESULTS: Eighty patients were seizure- and aura-free (63.3% ILAE 1), 16 continued to have auras (12.5% ILAE 2), and 13 experienced 1-3 seizure days per year after surgery (10.2% ILAE 3). Ninety-two patients were classified seizure-free (71.9% Engel I), and 17 had two or fewer seizures per year (13.3% Engel II). Of 110 patients in ILAE 1-3, 100 (91%) stated good or even very good postoperative HRQOL, and 99 (90.0%) reported improvements in HRQOL. Only 9 of the remaining 18 (50%) reported good or very good HRQOL after surgery (P=0.01). Corresponding results were obtained with Engel classes I and II, suggesting a trend toward ILAE 1-3 and Engel I and II as overall satisfactory outcomes. A more detailed HRQOL assessment yielded lowest scores in the cognitive domain, and a significant correlation of self-rated changes in cognitive functioning with seizure control (P=0.01). Changes in physical capabilities and mood were significantly better with satisfactory seizure outcome (P=0.006 and P<0.001, respectively), whereas the social aspects were not significantly dependent on seizure outcome (P=0.06). CONCLUSION: Correlation of HRQOL and seizure control suggested that ILAE 1-3 and Engel I and II most likely represent overall satisfactory outcome. Subdomain analyses revealed cognitive abilities as the most critical feature associated with seizure control, whereas social aspects remained mainly stable.

Processing of famous faces and medial temporal lobe event-related potentials: a depth electrode study.

The present study aims at analyzing the modulation of two types of event-related potentials originating from the human medial temporal lobe, the rhinal AMTL-N400 and the hippocampal P600 by the processing of famous faces. Therefore, we used a face recognition paradigm in which subjects had to discriminate the faces of famous persons from the faces of non-famous persons. Eleven patients with unilateral medial temporal lobe epilepsy undergoing intrahippocampal depth electrode recording for presurgical evaluation participated in this study. Event-related potentials (ERP) were recorded while a sequence of famous and non-famous faces was presented to the patients. The presentation of each face was repeated. The faces evoked N400-like potentials (anterior medial temporal lobe N400, AMTL-N400) in the rhinal cortex and P600-like potentials in the hippocampus. ERPs elicited by famous faces were contrasted with ERPs elicited by non-famous faces. The first presentation of famous faces elicited an enhanced AMTL-N400 and an enhanced hippocampal P600 in comparison to the second presentations of the famous faces or the (first and second presentation of the) non-famous faces. This findings are discussed in terms of associative semantic memory processes and the retrieval of person-specific information from long-term memory stores triggered by the processing of famous faces.

Calbindin-D28k content and firing pattern of hippocampal granule cells in amygdala-kindled rats: a perforated patch-clamp study.

The dentate gyrus is believed to play an important pathophysiological role during experimentally induced kindling. In this study, we investigated whether an altered content of the calcium binding protein calbindin-D(28k) or an increased intrinsic excitability of hippocampal granule cells contribute to the induction of the kindling phenomenon. We determined the firing pattern of granule cells in hippocampal slices using perforated patch-clamp recordings in current clamp mode. The expression of calbindin-D(28k) and glutamic acid decarboxylase (GAD(67)) by granule cells was analyzed immunohistochemically. Rats developed secondarily generalized limbic seizures within approximately 11 days of twice-daily stimulation of the amygdala. As reported for other kindling paradigms, this protocol induced a clear up-regulation of GAD(67) in granule cells, indicating their involvement in the induced neuronal activity. However, when comparing kindled and control rats, we could not detect any differences in intrinsic excitability: Firing frequency, after-hyperpolarisations, action potentials, input resistance and membrane potentials were nearly identical between both groups. Furthermore, we did not observe any differences in the calbindin-D(28k) immunoreactivity between groups. In every slice, virtually all granule cells were found to be strongly calbindin-D(28k) positive, and there was no apparent reduction in the general level of calbindin-D(28k) expression. We conclude that changes in intrinsic membrane properties or in the calbindin-D(28k) content of granule cells are not necessary for the development of amygdala kindling.