Hepatocellular carcinoma tumor thrombus entering the right atrium treated with combining percutaneous and intravenous high-dose-rate brachytherapy: a case report.

The presented report describes a case of a Hepatocellular carcinoma (HCC) tumor thrombus (TT) infiltrating the inferior vena cava (IVC) and the right atrium (RA) in a 66-year old male patient who initially presented with TT related symptoms. CT-guided high-dose-rate brachytherapy (HDRBT) was performed for both, the intraparenchymal primary and the TT. A marked improvement of the tumor-related symptoms and shrinkage of the tumor mass were achieved six months after treatment initiation. The combination of intravascular and percutaneous HDRBT demonstrating a promising approach to palliate tumor-related symptoms in advanced HCC with macrovascular invasion.

Venous thromboembolic complications with and without intermittent intraoperative and postoperative pneumatic compression in patients with glioblastoma multiforme using intraoperative magnetic resonance imaging. A retrospective study.

OBJECTIVE: To evaluate the effectiveness of intraoperative and postoperative intermittent pneumatic compression (IPC) as a method used to decrease the incidence of deep venous thrombosis (DVT), in comparison to the standard use of graduated compression stockings, low-molecular weight heparin (LMWH) and physiotherapy during the hospital stay. All patients in this study underwent intracranial surgery for glioblastoma multiforme (GBM) using intraoperative magnetic resonance imaging (MRI) guidance. PATIENTS AND METHODS: We performed a single center retrospective study of a cohort of 153 patients who underwent surgery for GBM aided by intraoperative MRI from October of 2009 to January of 2015 at the International Neuroscience Institute (INI), Hannover, Germany. Out of all patients, 75 in comparison to 78 were operated with and without the additional use of IPC, respectively. Both groups received graduated compression stockings, LMWH and physiotherapy postoperatively as a basic thromboprophylaxis. Postoperatively the patients were screened for DVT by Doppler ultrasonography of the limbs and pulmonary embolism (PE) by CT-scan of the chest. RESULTS: DVTs were found in 6 patients with IPC and in 3 patients without IPC. The incidence of developing DVTs was therefore not significantly increased with the application of IPC from 3.9% to 8% (P-value: 0.33). No statistically significant differences were found in the probability of occurrence of pulmonary embolism (PE) with a reduction from 2.6% to 1.3% (P-value: 0.59). CONCLUSION: Our results demonstrate, that the surgical intervention and the subsequent patient immobilization, as well as the thromboprophylactic techniques used have a relatively low influence on the occurrence of thromboembolic complications than we expected. Our findings might be attributed to the overall low number of these complications in a glioblastoma multiforme patient population expected to be at a high risk for coagulopathy. In other words, in order to produce statistically significant results, we would need to increase the patient cohort. By doing so we may better detect a positive therapeutic effect. Alternatively, because of the multitude of possible complex risk-factors leading to coagulopathy in a glioblastoma patient population it might be the case that IPC has little or no effect and that there is a different underlying mechanism responsible for the observed coagulopathy.

Image-guided craniotomy for frontal sinus preservation during meningioma surgery.

OBJECTIVE: Preservation of the frontal sinus (FS) during the frontolateral approach to the skull base reduces morbidity, enhances patient comfort, and speeds up the surgical procedure. Due to its irregular outline, mental reconstruction of the borders of FS from two-dimensional images is challenging during surgery. This study was designed to evaluate the impact of neuronavigation on identification and preservation of the FS during frontolateral craniotomies. METHODS: Forty-five patients with pathologies located in the anterior skull base and in the parasellar region were included. A standard computed tomography (CT) sequence was obtained from each patient and uploaded onto an image-guidance system for volumetric rendering of 3D images. The outline of the FS was visualized and the distance between its lateral border and the mid-pupillary line (MPL) was measured. The results were used for navigated craniotomies and compared to the intra-operative findings. RESULTS: The FS was located medial, on and lateral to the MPL in 32, 4 and 9 cases, respectively. The individual outline of the FS could be identified with a mean target registration error of 1.4mm (+/-0.7 mm). The craniotomy could be custom-tailored for each patient according to the individualized landmarks while visualizing the lesion and the surgical landmarks simultaneously. Unintended opening of the frontal sinus or orbit did not occur in any of these cases. CONCLUSION: Image-guided craniotomies based on 3D volumetric image rendering allow for fast and reliable demarcation of complex anatomical structures hidden from direct view in frontolateral approaches. The outline of the frontal sinus and the orbit can be appraised at a glance providing additional safety and precision during craniotomy.

The use of high-frequency electromagnetics in brain tumour surgery.

OBJECTIVE: The first commercially available high-frequency electromagnetic field (EMF) system promises additional functionality for neurosurgical procedures. In a prospective study, we evaluated the optimal use as well as the limitations of this system designed for vaporizing tissue and for coagulation in brain tumour surgery. METHODS: For the microsurgical treatment of 63 consecutive patients with various intracranial tumours, the EMF system was used in addition to the standard neurosurgical instrumentarium. The system was assessed with respect to its compatibility with the operating room environment. Furthermore, attention was given to the particular techniques required to use the system most effectively. The efficiency of the investigated tool was monitored throughout the study. RESULTS: The EMF system functioned properly in all procedures and did not cause any complications. Specific handling techniques and electrode tip configurations could be defined for optimal use of high-frequency electromagnetics for vaporization and coagulation in different intraoperative settings. Thereby, the efficiency of the device could be increased throughout the study while ineffective use decreased from 7 to 2 cases. Although this tool is designed ergonomically and offers high tactile control, it cannot be used submerged in cerebrospinal fluid or under continuous irrigation, which makes it necessary to use it in tandem with suction devices to obtain a clear view on the surgical field. CONCLUSION: Maneuvering with the EMF system was substantially different to both monopolar and bipolar systems, clearly necessitating a learning curve for the surgeon. This device was found to be a valuable complementary tool to standard electrosurgical instruments when applied effectively and with elaborated techniques.

[Three-dimensional-segmentation of the spine with specially adapted tools]. / 3-D-Segmentierung der Wirbelsäule mit speziell angepassten Werkzeugen.

Segmented 3-D data of the spine form the basis for various modern clinical applications. Among these, multisegmental image fusion, image registration and finite element modeling for biomechanical analysis are promising innovative tools capable of facilitating treatment decisions and optimization of individual therapy in the future. However, the complex anatomy of the spine and the often extensive degenerative deformation presenting in clinical practice, generally limit the application of fully automated segmentation. A newly developed software system is presented that meets the complex requirements for image segmentation of the spine through the use of specially adapted interactive tools that take account of its axial skeletal structure. Furthermore, a standardized protocol is introduced that combines the newly developed interactive tools (rotation transformation, warped dissection plane) and standard segmentation tools to permit rapid and accurate segmentation. To date, the software environment presented herein has been applied with success to the segmentation of cervical, thoracic and lumbar spine.

Temporal and regional profile of neuronal and glial cellular injury after induction of kaolin hydrocephalus.

AIM: To study regional and temporal pattern of glial and neuronal reaction to induction of kaolin hydrocephalus in adult rats. Enzyme- and immunohistochemistry was performed in 20 adult rats with kaolin-hydrocephalus after 2, 4, 6 and 8 weeks to glial glutamatergic transmission activity (GLDH) and neuronal nitrous oxide synthetic activity (nNOS). Also, glial fibrillary acidic protein (GFAP), 68 kd neurofilament protein (NF68) and synaptophysin (SYN38) and basic fibroblastic growth-factor (bFGF) were stained. Results were quantified by imaging analysis (SCION IMAGE) and expressed as relative immunopositive area. After 2 weeks, nNos-activity increased in cortical and hippocampal neurones (CA1 and CA3) and GLDH-activity also showed increases, most significant in periventricular white matter (25.7 +/- 3.8 vs. 15.5 +/- 4.9; p < 0.001) and hippocampus (p < 0.01). After 4 or 6 weeks, global cortical GLDH-activity showed further marked increases (25.7 +/- 3.9 vs. 11.3 +/- 1.5; p < 0.05), while sustained structural changes have occurred: GFAP decreased in periventricular (3.3 +/- 0.5 vs. 6.3 +/- 1.2; p < 0.01), hippocampal and cortical astrocytes (0.9 +/- 0.34 vs. 5.0 +/- 0.7%; p < 0.01), whereas NF68 in cortical efferent neurones increased (6.5 +/- 1.5% vs. 4.7 +/- 0.1; p < 0.01) followed by a decrease in cortical and hippocampal (CA1) SYN 38 (p < 0.05). Acute glial and neuronal reactions were almost functional and in chronic stages sustained structural changes predominated. Since neuronal reactions were pronounced in selective vulnerable areas glial reaction was not restricted to periventricular astrocytes.

Treatment of refractory pain after brachial plexus avulsion with dorsal root entry zone lesions.

OBJECTIVE: Significant numbers of patients experience intractable pain after brachial plexus root avulsions. Medications and surgical procedures such as amputation of the limb are often not successful in pain treatment. METHODS: Forty-seven patients with intractable pain after traumatic cervical root avulsions were treated with dorsal root entry zone coagulation between 1980 and 1998. The dorsal root entry zone coagulation procedure was performed 4 months to 12 years after the trauma, and patients were monitored for up to 18 years (average follow-up period, 14 yr). RESULTS: Immediately after surgery, 75% of patients experienced significant pain reduction; this value was reduced to 63% during long-term follow-up monitoring. Nine patients experienced major complications, including subdural hematomas (n = 2) and motor weakness of the lower limb (n = 7). Improved coagulation electrodes with thermistors that could produce smaller and more-accurate lesion sizes, which were introduced in 1989, significantly reduced the number of complications. CONCLUSION: Central deafferentation pain that persists and becomes intractable among patients with traumatic cervical root avulsions has been difficult to treat in the past. Long-term follow-up monitoring of patients who underwent the dorsal root entry zone coagulation procedure in the cervical cord indicated that long-lasting satisfactory relief is possible for the majority of individuals, with acceptable morbidity rates.

Arterial supply of the temporo-medial region of the brain: significance for preoperative vascular occlusion testing.

The mesiobasal limbic system is of particular significance in the surgical treatment of temporo-medial tumors and epilepsy. It consists of the uncus, amygdaloid body, hippocampus, dentate gyrus, subiculum, fasciolar gyrus and the parahippocampal gyrus. Knowledge of the vascular microanatomy is a key to the surgical treatment of pathologies in the region. The anterior choroidal artery was selectively injected in fresh brain specimens: 50 specimens with a gelatinous ink mixture to demonstrate vascular territories in stereotactic brain slices, and 50 with a Biodur resin to obtain casts for microanatomical evaluation. The cast technique was also applied to 35 specimens injected into the posterior cerebral artery. The rostral third of the temporomedial region is mainly supplied by branches of the anterior choroidal artery. The occipital two thirds are supplied by hippocampal branches, the posteromedial choroidal artery and the inferior temporal branches of the posterior cerebral artery. Important vessel variations with significant implications for the preoperative Wada-test are presented.

Spontaneous reanastomosis between lymphatic vessels following syngeneic transplantation of the small intestine in the rat.

Spontaneous lymphvascular reanastomosis (SLR) following small bowel transplantation in rats is of clinical relevance for the resorption of long chain fatty acids. Detailed morphological and molecular data concerning the process of lymphvascular reanastomosis are not available in the literature. In this study SLR was investigated using microradiology and scanning electron microscopy. Between the 8th and 21st postoperative days following transplantation SLR does not occur between the intestinal trunk of the transplant and the thoracic duct of the recipient. Instead, an indirect connection was observed between the inserted advential lymphatic vessels of the mesenteric artery and lymphatic vessels of the aorta or ductus deferens, which are connected with the thoracic duct.

Sporadic unilateral vestibular schwannoma with islets of meningioma: case report.

OBJECTIVE AND IMPORTANCE: Vestibular schwannomas with meningioma islets have been rarely reported in the literature; they have been observed only among patients with neurofibromatosis Type II. We present a case of a sporadic mixed tumor in a patient without neurofibromatosis Type II that was not suspected before surgery. CLINICAL PRESENTATION: A 59-year-old female patient presented with clinical signs of progressive loss of hearing. Her family history did not include evidence of neurological diseases. Magnetic resonance imaging scans revealed a typical unilateral vestibular schwannoma. INTERVENTION: The tumor presented with invasion of the surrounding arachnoid membrane, as well as Cranial Nerves VII and VIII. Preservation of the facial nerve with complete removal of the tumor was not possible. Therefore, Cranial Nerve VII reconstruction was performed. CONCLUSION: The concomitant occurrence of schwannomas and meningiomas infiltrating the arachnoid membrane might be related to poor clinical outcomes for patients with neurofibromatosis Type II, with respect to preservation of facial and acoustic nerves. Among sporadic schwannomas, this phenomenon is extremely rare.

Nomenclature, filling and angioarchitecture of lymph vessels in organs. Scanning electron microscopy of the stomach of the turtle Pseudemys scripta elegans using different injection methods.

The gastric lymph vessel network of Pseudemys scripta elegans shows all the characteristics of initial lymphatics. A differentiation of initial lymphatics in lymphatic capillaries and precollectors is not possible in the turtle. The scanning electron microscopic examination shows that ultrastructural analysis of initial lymphatics is possible after manual subserous injection of glutaraldehyde or application with the vacuum chamber. In the stomach of the turtle all characteristics of initial lymphatics (interendothelial openings, subendothelial filaments, connective tissue trabeculae and endothelial bridges) could be demonstrated. Only valves were absent. The situation is similar in mammals including man. The most important filling phenomenon is a horizontal spreading of fluid in the lymphatics.

Dynamic properties of lymphatic pathways for the absorption of cerebrospinal fluid.

To study the dynamics of the outflow of cerebrospinal fluid (CSF) into the cervical lymphatic system, X-ray contrast medium or Indian ink was infused into the cisterna magna of rats at moderately increased intracranial pressure (40-50 mmHg). In the first series of experiments, while the contrast medium was being infused, the animal's head was examined using X-ray-microscopy (x4-20 direct magnification radiography) and conventional radiography. Within the first minutes of infusion, the flow of CSF was directed from the posterior fossa to the olfactory bulb. Reaching the cribriform plate approximately 7 min after starting the infusion, the contrast medium leaked into the nasal cavities. Some minutes later, it opacified the subarachnoid space (SAS) of the optic nerve, the perilymphatic space of the inner ear, the cortical SAS, and the transverse sinuses. Leakage from the optic nerve SAS into the orbit was seen after 30 min infusion. In the second series of experiments, the Indian ink was infused after microsurgical exposure of the cervical lymph vessels. During the infusion the cervical lymph ducts were observed microscopically (x40 magnification). Single dye particles draining through the cervical lymph ducts appeared 20 min after the start of cisternal infusion. Their transport was rapid, and dependent on the respiratory cycle: during inspiration the particles moved at a speed of 10-20 mm/s, during expiration the movement stopped. Thus, rapid kinetics are demonstrated for the outflow of CSF and particles from the SAS into the cervical lymphatics.

Cerebellopontine angle lipoma: a rare differential diagnosis.

Intracranial lipomas in an infratentorial and extra-axial location are extremely rare. The presented case of an extensive lipoma of the cerebellopontine angle (CPA) represents 0.05% of all CPA tumors operated on in our department from 1978 to 1996. The lipoma constitutes an important differential diagnosis because the clinical management differs significantly from other CPA lesions. The clinical presentation and management of the presented case are analyzed in comparison to all previously described cases of CPA lipomas. The etiology and the radiological features of CPA lipomas are reviewed and discussed. CPA lipomas are maldevelopmental lesions that may cause slowly progressive symptoms. Neuroradiology enables a reliable preoperative diagnosis. Attempts of complete lipoma resection usually result in severe neurological deficits. Therefore, we recommend a conservative approach in managing these patients. Limited surgery is indicated if the patient has an associated vascular compression syndrome or suffers from disabling vertigo.

Breakdown of the meningeal barrier surrounding the intraorbital optic nerve after experimental subarachnoid hemorrhage.

PURPOSE: The intraorbital optic nerve sheath meninges contain a perineural subarachnoid space lined by meningeal cell layers and intercellular fibrous tissue. We sought to determine whether functional or structural characteristics, or both, of the optic nerve sheath are influenced by the increased intracranial pressure after the rupture of cerebral aneurysms. METHODS: We infused the great cisterns of cats with either x-ray contrast medium or autologous blood. The cisternal infusions were done under the experimental condition of a sudden 2.5-minute increase in intracranial pressure similar to that recorded after the rupture of cerebral aneurysms in humans. RESULTS: Digital subtraction radiographs of the optic nerves taken during the cisternal infusion of contrast medium at the start showed the opacification of the optic nerve subarachnoid space. After 2 minutes, the contrast medium leaked into the orbit, indicating the breakdown of the meningeal fluid barrier. Ultrastructural investigation of the optic nerve sheath after high-pressure cisternal infusions showed the arachnoid cell layers scattered. The flattened arachnoid cells displayed mainly intracellular and some intercellular, porelike openings. After infusion of blood into the great cistern, erythrocytes were found within porelike openings of the arachnoid cells. CONCLUSIONS: The meningeal fluid barrier of the optic nerve sheath can be destroyed by pressure changes associated with subarachnoid hemorrhage. This disruption might be regarded as a natural optic nerve sheath fenestration that allows outflow of cerebrospinal fluid into the orbit to protect the optic nerve from increased intracranial pressure after aneurysmal rupture.

Recent findings on the angioarchitecture of the lymph vessel system of human skin.

The regional distribution of initial (i.e. most peripheral) lymph vessels of the human skin is unknown. New methods permit a precise systematic determination of the density of initial lymph vessels in every region of the dermis. Based on 202 skin specimens, it was possible to investigate the density of the lymph vessels of the skin derived from head, neck, upper arm, forearm, upper and lower leg. In all regions there seem to be a uniform structured dense subpapillary network and a wide meshed deep dermal network. The lymph vessels are at their most dense in the skin of the head.

Solid-state anomalies in IR spectra of compounds of pharmaceutical interest.

Solid-state anomalies in the IR spectra of lysine monohydrochloride, etoxadrol hydrochloride, thiamine hydrochloride, and L-histidine in a potassium bromide matrix were noted. With the first three compounds, the anomalies were due to metathetical exchange of the halide anion between the compound and the matrix. The anomaly seen with L-histidine was related to the crystal structure.